SPECIAL  DENTAL  PATHOLOGY 


A  WORK 


ON 


SPECIAL  DENTAL 
PATHOLOGY 


DEVOTED   TO   THE 


DISEASES  AND  TREATMENT 


OF   THE 


Investing  Tissues  of  the  Teeth  and 
THE  Dental  Pulp 


INCLUDING  THE  SEQUEL.E  OF  THE  DEATH  OF  THE  PULP; 

ALSO,  SYSTEMIC   EFFECTS  OF  MOUTH   INFECTIONS, 

ORAL  PROPHYLAXIS  AND  MOUTH  HYGIENE 


518    ILLUSTRATIONS 


BY 

G.  V.  BLACK,  M.D.,  D.D.S.,  SC.D.,  LL.D. 

DEAN  AND  PROIESSOR  OF  OPERATIVE  DENTISfRY,  DENTAL  PATHOLOGY  AND   BACTERIOLOJY 
NORTHWESTERN  UNIVERSITY  DENTAL  SCHOOL 


1915 

MEDICO-DENTAL  PUBLISHING  COMPANY 
CHICAGO 

CLAUDIUS  AvSH,  SONS  &  COMPANY 
LONDON 


Entered,  according  to  Act  of  Congress,  in  the  year  1915, 

by  G.  V.  Black, 

In  the  Office  of  the  Librarian  of  Congress,  Washington,  D.  C. 


Entered  at  Stationers'  Hall, 
London,  Eng. 


»HtSS  or  THE  MCNRv  O     SMfPARO  CO..  CHICAOC- 


3^//^ 


/^/^ 
PREFACE 

THE  writing  of  this  book  was  begun  five  years  ago,  and  its 
completion  lias  been  delayed  in  order  that  I  might  carry  out 
long  lines  of  experimental  work  upon  several  subjects  which 
needed  further  investigation. 

In  the  prosecution  of  the  work,  I  have  continually  had  the 
cooperation  and  advice  of  my  sons,  Dr.  Carl  E.  Black,  of  Jack- 
sonville, Illinois,  and  Dr.  Arthur  D.  Black,  of  Chicago,  which  has 
been  a  veiy  efficient  aid. 

My  thanks  are  due  the  Research  Institute  of  the  National 
Dental  Association  for  a  five  months'  assignment  of  Dr.  H.  A. 
Potts,  to  assist  me  in  carrying  out  investigations  in  my  labora- 
tory. I  am  under  obligation  to  Dr.  Thomas  L.  Gilmer,  Dr.  E.  S. 
Wiilard,  Dr.  William  Bebb,  Dr.  F.  D.  Leach,  Dr.  H.  A.  Potts, 
Dr.  F.  B.  Noyes,  and  Dr.  E.  A.  Schniedwind  for  suggestions  and 
assistance.  A  number  of  the  members  of  the  classes  of  1914  and 
1915  of  Northwestern  University  Dental  School  have  aided,  par- 
ticularly in  experiments  in  collecting  deposits  of  salivary  cal- 
culus and  in  testing  the  effects  of  various  drugs  upon  the  tissues. 

The  preparation  of  the  illustrations  and  the  final  copy  has 
been  almost  wholly  under  the  management  of  Dr.  Arthur  D. 
Black,  who  has  been  in  close  touch  with  me  constantly  in  this 
work.  At  my  request,  he  has  also  written  the  article  on  Exam- 
inations of  the  Mouth,  and  Dr.  Carl  E.  Black  has  supplied  a  com- 
pilation of  the  principal  events  leading  to  the  development  of 
antiseptic  and  aseptic  surgery. 

I  am  under  special  obligation  to  my  daughter.  Miss  Clara 
Black,  and  to  Mrs.  Arthur  D.  Black,  for  valuable  assistance  in 
proofreading. 

To  all  of  these  I  wish  to  express  my  thanks. 

G.  V.  BLACK. 
Chicago,  April  12, 1915. 


TABLE  OF  CONTENTS. 


Note. —  This  table  of  coutents  has  been  prepared  for  use  as  an  outline  by  stu- 
dents or  practitioners  who  desire  to  make  a  careful  synopsis  in  connection  with  the 
study  of  the  subjects  presented.  All  headings,  subheadings  and  paragraph  headings 
in  the  book  are  given  in  proper  order,  and  the  relations  of  these  are  shown  by  the 
positions  of  the  headings  m  this  table. 


PAGE 

Preface   iii 

Introduction 1 

Investing    Tissues   of   the    Teeth  —  The    CJingiv.?-:,    Peridental 
Membrane,   Cementum   and   Auveouar   Process.     Histology 

AND  Physical  Functions 7 

Gums  and  Gingivae 7 

The   Fibrous   Mat 8 

Epithelium    i  9 

Blood    9 

Sensation   9 

Healing  Powers   11 

OiNGiv.^i:  11 

Parts  of  the  Cingivte 13 

Body  of  the  GingivjK 13 

Groups  of  Fibers  in  Gingivas  and  Peridental  Membrane.  .  .  14 

The  Free  Gingivae  Group li) 

The  Trans-Septal  Group 15 

The  Alveolar  Crest  Group 16 

The  Free  Gingivae 16 

The  Septal   Gingivte 17 

Epithelium  of  the  Gingivte 19 

Epithelium  of  the  Septal  Gingiva? 20 

The  Hormone 21 

Development  of  the  (Jingivae 22 

The  Subgingival  Spaces .  24 

Exploration  of  the  Subgingival  Spaees 25 

Functions  of  the  (Jingiva' 26 

A  Protective  Tissue 26 

Maintenance  of  Teeth  in  the  Line  of  the  Arch 28 

(vii) 


Vlll  SPECIAL   DENTAL   PATHOLOGY. 

PAGE 

Cementum,  Peridental  Membrane  and  Alveolar  Process 30 

Histological  Studies  of  the  Peridental  Membrane 30 

Cementum 31 

Differences  between  Cementum  and  Bone 32 

Cementum  does  not  Repair  Injuries 32 

Cementum  Subject  to  Absorption 32 

Absorption  of  Roots  of  Permanent  Teeth 33 

Attachment  of  Principal  Fibers  of  the  Peridental  Membrane  to 

the  Cementum    34 

Cementum  Continuous  Growing 34 

ITypercementosis 35 

Cementum  in  Animals 35 

Peridental  Membrane 36 

Fibers  of  the  Peridental  Membrane 36 

Horizontal  Group 37 

Obli(iue  Group   37 

Apical  Group   39 

Indefinite  Connective  Tissue 40 

Blood  Vessels  40 

Nerves 40 

Osteoblasts 41 

Cementoblasts   42 

Epithelium    43 

Physical  Powers  of  the  Peridental  Membrane  and  Cementum, 

AS  Shown  by  Planted  Teeth 45 

Planting  of  Teeth 45 

Replantation    46 

Transplantation    46 

Implantation   47 

No  Histo-Pathological  Studies  of  Planted  Teeth 47 

Chemotaxis    48 

Attachment  of  Planted  Teeth  Physiologically  Unstable 49 

Ai.veolar  Process  .  .i 50 

Alveolar  Processes  Are  Bone 51 

Development  of  the  Alveolar  Process 52 

When  the  Teeth  Are  Malposed 53 

When  Teeth  Are  Extracted r)3 

Results  of  a  Break  in  the  Peridental  Membrane 53 

Movement  of  Teeth  Suteequent  to  Extractions 54 

Saliva    .  ., ^-^ 

Ptyaliii   56 


TABLE    OF    CONTENTS.  IX 

PAGE 

Mucus 58 

Albumin   60 

Salivary  Corpuscles,  so  called 61 

Investing    Tissues   of   the   Teeth  —  The   Gingivae,    Peridental 
Membrane,  Cementum  and  Alveolar  Process.    Diseases  and 

Treatment    62 

Brief  Historical  Review  of  the  Development  of  Our  Knowledge 

of  the  Diseases  of  the  Investing  Tissues 64 

Names  Applied  to  Diseases  of  the  Investing  Tissues ,.  . .  64 

Kiggs '  Disease 64 

Pyorrhea  Alveolaris 64 

Phagedenic  Pericementitis   65 

Chronic  Suppurative  Pericementitis 65 

Calcic  Gingivitis 6o 

Calcic  Pericementitis 65 

Alveolitis   65 

Dento- Alveolar  Pyorrhea ■  •  66 

Interstitial  Gingivitis   66 

Dr.  Riggs'  Treatment 66 

Dr.  Rehv^ankel's  Paper 67 

Gouty  Diathesis  as  a  Theory 67 

Special  Infection  Theory 68 

Serum  Treatment '0 

The  Treatment  in  Vogue '''I 

Studies  of  Salivary  Calculus 73 

Composition   '  -^ 

Analysis '^^ 

Studies  of  Deposit  of  Salivary  Calculus 75 

Dr.  Burchard's  Studies '^6 

Personal  Investigations  of  the  Deposit  of  Salivarv^  Calculus.  ...  79 

Test  of  Saliva  for  Precipitate  of  Calcium  Salts 79 

Examination  of  Deposits  on  Artificial  Dentures 80 

Collection  of  Deposit  on  Cover-glass 81 

Staining  82 

Deposits  Classified  ^'* 

J                 Paroxysmal  Characters 84 

Gathering  CalculiLs  Direct  from  the  Parotid  Gland 86 

Globulin 88 

Agglutinin  of  Salivary  Calculus 89 

Consi.steufjy  of  the  Spherules 89 

Globulin  and  Salts  Inseparable -^1 

Deposits  Dui'ing  Illness ^1 


X  SPECIAL    DENTAL   PATHOLOGY. 

PAGE 

Chemistry  of  the  Deposits 93 

IFardening  of  Salivar}'  Calculus 94 

Knowledge  of  Hardening  Basis  for  Prophylactic  Teach- 
ing   95 

Explanatory  Supposition    95 

Calco-globulin  iu  Other  tSecrotions 96 

Conclusion  97 

Gingivitis  and  Pericementitis  Due  to  Deposits  of  Salivary  Cal- 
culus     99 

Cingivitis.     Beginning  .-uul  Progress  of  Deposit. 99 

Sui)puration    100 

Pericementitis.    Destruction  of  Deeper  Tissues 100 

Attachment  of  Peridental  Membrane  to  Hoot  Mnintaincd  to 

Level  of  Soft  Tis.sue  Remnining. 100 

Pain  and  Soreness 101 

Teeth  Become  Loose  and  Are  Finally  Lost 101 

IMenace  to  General  Health 102 

Variations  in  the  Position  and  Progress  of  the  Deposit 102 

Deposit  Usually  Confined  to  Certain  Teeth 102 

Conditions  Contributing  to  Occurrence  of  Deposit 102 

Form  Which  Gives  Opportunity  for  Initial  Deposit 103 

Forms  of  Artificial  Dentures  to  Avoid  Deposits 104 

Lifiuence  of  Masticntion  in  Preventing  Deposits 104 

Treatment  of  Gingivitis  and  Pericementitis  Due  to  Dkposits  of 

Salivary  Calculus 105 

Pemoval  of  Deposits  ;uid  Care  of  Tissues  by  the  Dentist 106 

Instruments  and   Instrumentation 106 

Care  of  Tissues  by  the  Dentist 109 

Ciire  by  the  Patient 110 

Subsequent  Examinations    Ill 

Fixation  of  Teeth   That  Have  Been  Loosened  as  a   Result  of 

Deposits  of  Salivary  Calculus 112 

Gingivitis  Due  to  Deposits  or  Serumal  Calculus 115 

Causes  of  Deposit  and  Conditions  of  Occurrence 115 

Comparison  of  Serumal  vvilli  Salivaiy  Calculus 117 

The  Gingivitis  Due  to  the  Deposit 117 

Compression  of  Deposits  by  the  Gingivre 118 

Variations  in  liocation  of  Dcj>osits 118 

Suppuration  Involving  Peridental  Membrane 118 

Treatment  op  Gingivitis  Due  to  Deposits  of  Serumal  Calculus.  120 

Removal  of  Deposits  and  Care  of  Tissues  by  the  Dentist 120 

Care  of  Tissues  bv  the  Dentist 123 


TABLE    OF    CONTENTS.  XI 

PAGE 

Care  by  the  Patient •  •   124 

Subsequent  Examinations 124 

Gingivitis  Caused  by  Injuries 125 

General  Statement  of  Causes  and  Symptoms 126 

Inflannnation 126 

Snppiuation    l*-' 

Complaint  of  Pain  Variable 127 

Absorption  of  Septal  Tissue 128 

Deposits  of  Serumal  Calculus. 128 

Classification  of  Conditions  Causing  Injuries  of  the  Gingiv.e. .  .   129 

Gingivitis  Due  to  Lack  of  Contact  of  Teeth 129 

Separations  Following  Extractions 129 

Abnormalities  of  Occlusion l-^O 

Uneven  Occlusal  Wear l'^f> 

Weak  Contacts  I'^O 

Decays  Beginning  in  Proximal  Surfaces I'^l 

Fillings  and  Crowns  \Yhich  Fail  to  Make  Contact 131 

Gingivitis  Due  to  Improper  Contact  of  the  Teeth 131 

Abnormal  Forms  of  the  Teeth 131 

Malpositions  of  the  Teeth 132 

Interproximal  Wear 132 

Improperly  Finished  Fillings  and  Crowns 133 

Gingivitis  Due  to  Deviations  from  the  Normal  Smooth  Con- 
tour of  Tooth  Surfaces , 134 

Sharp  Edges  of  Cavities 1-^-^ 

Imperfect  Margins  of  Fillings 134 

CroAvns,  Bridges  and  Partial  Dentures 134 

Gingivitis  Due  to  Abuse  of  Tissues  by  Dentists  in  Operating  135 

Injuries  with  Ligatures .  .; 1-^'^ 

Injuries  with  Finishing  Instruments  and  Tapes 1:56 

Failures  to  Remove  Ligatures  and  Pieces  of  Kul)l)('r 

Dam l;!^ 

Other  Abuses l'*5j 

Gingivitis  Due  to  Lack  of  Cleatiliness 13^ 

Lack  of  Natural  Cleaning 1''^ 

Lack  of  Artificial  Clenning l'"^"^ 

Gin^^ivitis  Due  to  Errors  in  Cleaning  Operations,  Accidents, 

"        etc l-'8 

Misuse  of  Toothpicks '•^*^ 

Misuse  of  Rubber  Bands  and  Silk  Floss 139 

Injuries  with  the  Tooth-brush 1-^^ 

Accidental  Inj\iri.'s  lo  the  Gingiva- l'^9 


XI 1  SPECIAL    DENTAL   PATHOLOGY. 

PAGE 

Frequency  of  Different  Forms  of  (Jingivitis 139 

History  of  the  Attitude  of  the  Profession  Toward  Injuries  of  the 

Gingivae ' 141 

TTse  of  Non-cohesive  CJold  and  the  Filing  of  V-shaped  Spaces  142 

Discoveiy  of  the  Cohesive  Property  of  (iold  Foil 142 

Wooden  Wedge 144 

Diseover^^  of  the  Rubber  Dam 145 

Physiological  Importance  of  Tooth  Forms 145 

Treatment  of  Gingivitis  Due  to  Injuries 147 

In  Cases  of  Lack  of  Contact 148 

Danger  of  Disturbing  the  Occlusion 149 

In  Cases  of  Improper  Contact 150 

Other  Conditions   151 

More  Careful  Study  of  Cases  Necessaiy 151 

An  Exact  IMethod  of  Separation  Necessary  to  Success  in  Build- 
ing Proper  Contacts 152 

Perry  Separator 153 

Chronic  Suppurative  Pericementitis 159 

Causes  Leading  to  Formation  of  Pus  Pockets 161 

(iingivitis  Always  Precedes 161 

Deposits  of  Serumal  Calculus  on  Enamel 161 

Injuries  to   Gingiva^ 161 

Systemic  Conditions 161 

Specific  Infection 162 

Endameba  Buccalis  162 

Symptoms  and  Tissue  Changes 164 

Locations  of  Pus  Pockets 164 

Changes  in  the  Tissues 165 

Appearance  of  the  Gingivae 165 

Infection  and  Detachment 166 

Pockets  Progress  Most  Toward  Apex  of  Root 167 

Failures  of  Reattachment 167 

Cases  Tend  to  Progress 168 

Destruction   of   Cementoblasts,    Fibers   of   Peridental 

Membrane,  and  the  Alveolar  Process 168 

Absorption  of  Alveolar  Process  Best  Shown  by 

Radiographs 169 

Granular  Condition  of  Soft  Tissue  Covering  Root.  . . .   171 
Absorption  by  the  Denuded  Cementum  of  Products  of 

Suppuration  and    Putrefaction 171 

Complaint  of  Pain 172 


TABLE    OF    CONTENTS.  Xlll 

PAGE 

Deposits  of  JSenimal  Calculus 172 

Deposit  Often  Nodular 172 

Occurrence  of  Deposits. 173 

Deposits  Contribute  to  Progress 173 

Enlargement  of  Cervical  Glands 174 

Palpation   of   Submaxillary   and   Cervical   Lymphatic 

Glands    174 

Excitation  of  Salivary  Glands . 175 

Movements  of  the  Teeth  as  a  Result  of  Pocket  Formation .  .   175 

Labial  Movement  of  Upper  Incisors .  .  .   176 

Teeth  May  Move  Forward  of  Normal  Position  of 

Labial  Process    177 

Multiple  Pocket  Formation 178 

Gingival    Abscess,    Septal   Abscess   and   Lateral    Alveolar 

Abscess 179 

Differential  Diagnosis  from  True  Alveolar  Abscess.  .  .   181 
Admixtures  of  Chronic  Suppurative  Pericementitis  and  Inflam- 
mations Caused  by  Deposits  of  Salivary  Calculus 182 

Treatment  of  Chronic  Suppurative  Pericementitis 185 

The  Key  to  the  Treatment 185 

Preventive  Treatment 186 

Plan  for  Preventive  Treatment 186 

Preventive  Treatment  Must  Be  by  General  Practitioner  of 

Dentistiy    187 

Systematic  Observation  and  Institution  of  Treatment  Early  187 
Care  to  Avoid  Injury  to  Soft  Tissues  in  All  Operations.  .  .  .   188 

Injuries  to  the  Septal  Tissues 188 

Injuries  to  Lingual  of  the  Tapper  Incisors 189 

Training  of  Patients 189 

Palliative  Treatment 190 

Plan  for  Palliative  Treatment 191 

Removal  of  Deposits  and  Care  by  the  Dentist 191 

Instruments   192 

Instrumentation    192 

Finger  Skill  Very  Essential 194 

Scalers  ^Must  Be  Sharp 194 

Leave  Roots  Smooth 195 

Pain  in  Scaling  Operations 196 

Care  of  Tissues  by  the  Dentist 197 

Care  by  the  Patient 197 

Subsequent  Examinations 198 

Administration  of  Emetin  llvdrochlorate 199 


XIV  SPECIAL   DENTAL    PATHOLOGY. 

PAGE 

Surgical  Treatment  of  Pockets 199 

Tlie  Use  of  Splints 201 

Radical  Treatment 202 

When  Indicated   202 

Amputation  of  ]xoots 20.1 

Management  of  Cases  of  Chronic  Suppurative  Pericementitis.  .  .   206 

Examination    206 

Kadiographs 207 

Plan  of  Treatment  for  Eacii  Case 208 

Sentiment  in  Relation  to  the  Treatment  of  Diseases  of  the 

Peridental  Membrane   209 

Al)andonment  of  Antiseptics  in  the  Treatment  of  Chronic  Su})- 

purative  Pericementitis    210 

Defense  by  the  Tissues 218 

Treatment  by  Cleanliness \ 213 

Development  of  Antiseptic  and  Aseptic  Suugery  and  the  Use 

OF  Antiseptics 217 

Preparatorj'^  Period  . 217 

Antiseptic  Period 218 

Aseptic  Period   220 

Use  of  Antiseptics  Gradually  Lessened 220 

Chemotaxis  and  Phagocytosis 221 

Personal   Studios    222 

Chronological  List  of  the  Principal  Events  in  the  Development 

op  Antiseptic  and  Aseptic  Surcekv 225 

Acute  Ulcerous  Gingivitis 230 

Dentaij  Pulp.    Histology  and  Physical  Functions 235 

Cellular  Elements 235 

Odontoblasts.    Fibrils  of  Tomes 230 

Blood  Vessels 236 

Walls  of  Blood  Vessels .; 237 

Nerves  and  Nei-ve  Functions 238 

Sensory  Function  of  the  T'ulp 239 

Pain  and  Touch 240 

Pulp  an  Internal  Organ 241 

Pain  of  Other  Diseases  Simulates  Pulp  Pain 242 

Sense  of  Touch  Is  in  Peridental  Membrane 243 

Healing  Powers   243 

History  of  Efforts  to  Save  Exposed  Pulps  by  Capping.  244 

Diseases  of  the  Dental  Pulp 248 

Historical  Statement  248 


TABLE    OF    CONTENTS.  XV 

PAGE 

Personal  Studies  of  Hyperemia  and  Inflammation  of  tlic  f'lilp.  .   251 
Teehnie  of  Preparing  Specimens 251 

Hyperemia  of  the  Dental  Pulp 254 

Etiology   254 

Pathological  Changes 255 

Symptoms 25G 

SequeljE    25G 

IneIjAmmation  of  the  Dental  Pl  lp 258 

Etiology  258 

Pathological  Changes 259 

Diagnosis   261 

Exposed  to  Carious  Dentin 261 

Pain    261 

Chronic  Inflammation  of  the  Pulp 262 

Hypertropli}^  of  the  Dental  Rilp 262 

Diiignosis   263 

Treatment    264 

Calcifications  in  the  Pulp  Chamber  and  Their  Ept^^ects  Upon 

THE  Pulp   Tissue 265 

Classification  265 

Personal  Investigations ,  .^ 266 

Calcifications  Attached  to  the  Walls  of  the  Pulp  Chamber 267 

Etiology 267 

Nature  and  Conditions  of  Growth 268 

Protection  for  Pulp 268 

Calcifieation  More  Extensive  as  Abrasion  Progresses.  .  268 
Secondary  Dentin  Deposited  Through  Reflex  Action ; 

Not  a  Local  P'ovmation 269 

Effect  upon  the  Dentin  and  Enamel 271 

Abraded  Dentin  Becomes  Darker.    Fibrils  Die 271 

Exposure  of  Pulp  by  Abrasion  and  Erosion 272 

Effect  upon  the  Pulp 272 

Danger  of  Alveolar  Abscess 274 

Calcifications  Growing  Free  in  the  Tissue  of  the  Pulp,  Unat- 
tached to  the  Walls  of  the  Pulp  Chamber 274 

Variety  of  Forms 274 

Generally  No  Symptoms 276 

Tendency  to  Destroy  Pulp 276 

Treatment  for  Limitation  of  Calcifications  Within  the  Pulp 

Chamber    276 

Treatment  of  Abnision 277 


XVI  SPECIAL    DENTAL    PATHOLOGY. 

PAGE 

Building  Up  of  Extensive  Abrasions 278 

Danger   of   Ajiproachiug    Too    Close    to    Pulp    in    Cavity 

Preparation 279 

Treatment  of  Erosion   279 

Formation  of  Calco-Spiierites 280 

Artificial  Formation  of  Calco-Spherites 281 

Importance  of  Studies  of  Calco-Spherites 283 

Technic  of  Treatment  of  the  Dental  Pulp 286 

General  Considerations 286 

Asepsis  287 

Plan  for  Aseptic  Technic 288 

Application  of  the  Rubber  Dam 288 

Sterilization  of  Field 289 

Sterilization  of  Instruments,  Dressings,  etc 289 

Sterilization  of  Broaches  Wrapped  \nth  Cotton 289 

Technic  of  Wrapping  Cotton  on  Broaches 290 

Surgically  Clean  Hands 292 

Sealing  Treatments  292 

Technic  of  Sealing  Treatments  with  Base-Plate  Gutta- 
percha    292 

Rationale  of  Pulp  and  Root  Canal  ^Medication 295 

Experiments  with  ^lodicaments  Used  in  Pulp  Treat- 
ment      296 

Preventive  Treatment  of  Hyperemia  and  Inflammation  of 

the  Pulp 298 

Thorough  and  Frequent  Examinations 299 

Avoid  Near  Approach  and  Exposure  of  Pulp  in  Cavity 

Preparation   299 

Use  of  Non-Con ductors 300 

Treatment  of  Hyperemia 300 

Capping  Exposures  of  the  Dental  Pulp 301 

Time  of  Complete   Calcification  of  the  Roots  of  the 

Various  Teeth 303 

Indications  for  Capping 303 

Technic  of  Capping 303 

Treatment  of  Vital  Dental  Pulps 304 

Exposure  of  the  Pulp 304 

Conditions  Presenting  304 

Opening  the  Cavity 304 

Rubber  Dam  On 305 

Make  Exposure  with  Broad  Instrument 305 

In  Bicuspids  and  Molars 305 


TABLE    OF    CONTENTS.  XVI 1 

PAGE 

III  Proximal  Cavities  in  Incisors 306 

Medication  to  Reduce  Inflammations 306 

When  Pain  Is  Uncontrollable 307 

Destroying  the  Dental  Pulp  with  Arsenic 307 

Avoid  Pressure  in  Sealing 307 

Danger  of  Arsenical  Poisoning 308 

Subsequent  Treatment  of  Pulp  Only  Partly  Devitalized.  .  .   308 

Anesthetizing  the  Dental  Pulp  with  Cocain 308 

Requires  Pressure  to  Secure  Anesthesia 309 

When  Pulp  Is  Not  Actually  Exposed 309 

Opening  the  Pulp  Chamber  Preparatory  to  Removal  of  the  Pulp  310 

Occlusal  Cavities  in  Molars 310 

Proximal  Cavities  in  Molars 312 

Cavities  in  Bicuspids 312 

Cavities  in  Incisors  and  Cuspids 312 

Removal  of  the  Pulp '^1^ 

Broaches ^^^ 

Technic  of  Removal ,  . . .  314 

Location  of  Canals  in  Upper  Molars 314 

Location  of  Canals  in  Lower  Molars 316 

Variations  in  the  Forms  of  Pulp  Chambers 318 

Opening  Pulp  Chambers  in  Sound  Teeth 318 

In  Incisors  and  Cuspids 318 

In  Bicuspids  and  Molars 320 

Treatment  of  Teeth  Having  Dead  Pulps 321 

Conditions  Presenting 321 

Technic  of  Treatment.     Asepsis 322 

Instrumentation    ^^^ 

Seal  Treatment -^23 

Danger  of  Periapical  Infection 323 

Treatment  of  Pulp  Chambers  Which  Have  Been  Narrowed  by 

Calcific  Deposits "^^^ 

Removal  of  Calcifications  from  Root  Canals 325 

Removal  of  Previous  Root  Canal  Fillings 325 

Fii;LiNG  Root  Canals -^^^ 

Size  of  Foramen  and  Length  of  Canal 326 

Technic  for  Large  Canals 3-7 

Rationale  of  this  Procedure ^28 

Technic  for  Small  Canals 328 

Canals  Grouped  into  Two  Classes 329 

To  Prevent  Evaporation  of  Chloro-percha '. 329 

Horns  of  Pulp  Chamber •**"'^ 

b 


XVlll  SPECIAL    DENTAL    PATHOLOGY. 

PAGE 

Treatment  of  Pulps  of  Deciduous  Teeth 330 

Time  of  Complete  Calcification  and  Beginning  Absorption  of 

Roots 330 

Serious  Results  from  Exposures  of  Pulps  of  Deciduous  Teeth.  .  331 

Technic  Same  as  for  Permanent  Teeth 332 

Chronic  Abscesses 333 

Better  Care  Desirable 333 

Filling  of  Deciduous  Teeth 334 

Acute  Alveolar  Abscess 336 

Etiologj'  336 

Pathological  Changes    337 

Apical  Pericementitis  and  Pus  Foi-mation 337 

Absorption  of  Bone 337 

If  Pus  Penetrates  Periosteum 340 

If  Pus  Lifts  Periosteum  from  Bone 340 

Variations  in  Burrowing  of  Pus 340 

Distinctions  between  Alveolar  Abscess  and  Abscesses  Occun-ing 

Elsewhere 341 

Infection  from  Pulp  Chamber  of  a  Tooth 341 

Denuded  Cemcntum  Maintains  Chronicity 341 

Symptoms    343 

Constitutional  Symptoms  343 

Local  Symptoms 343 

Tenderness  of  Tooth 343 

Pain  and  Swelling 344 

Ball-like  Tumor   344 

Flat  Tumor 345 

Painful  Symptoms  Disappear  with  Discharge  of  Pus.  .   345 
Difi'erential    Diagnosis   between   Acute    Alveolar    Abscess   and 

Certain  Other  Conditions 345 

Sarcoma  346 

Gumma 346 

Aneurism   346 

Cysts 346 

P^xamine  Fluid  Contents 347 

Glands 347 

Eruption  of  Third  ^lolars 347 

Treatment  op  Acute  Alveolar  Abscess 350 

During  Apical  Pericementitis 350 

Secure  Good  Drainage 351 

Through  Pulp  Chamber 351 

Through  Investing  Tissues 351 


TABLE    OF    CONTENTS.  XIX 

PAGE 

Advantages  of  Early  Incision .  < 352 

Incision  Should  Be  Ample  for  Good  Drainage 352 

If  a  Broad  Flat  Tumor  Under  Periasteum 353 

If  Pus  Has  Not  Reached  Periosteum 353 

Anesthesia  for  Incision 353 

Opening  Made  with  Phenol 353 

Irrigation    354 

Packing 354 

Open  Pulp  Chamber  after  Acute  Symptoms  Have  Subsided  355 

Treatment  of  the  More  Severe  Cases 355 

Relief  of  Pain  and  General  Symptoms 356 

Hot  Fomentations 356 

Saline  Cathartic.     Hot  Fwt  Bath 356 

Anodyne 356 

Drainage 357 

Burrowing  of  Pus 357 

Prophylaxis  as  Applied  to  Alveolar  Aliscess 300 

Chronic  Alveolar  Abscej^s 362 

Etiology   . 362 

Pathological  Changes    363 

Destruction  of  the  T'eriapical  Tissues 363 

If  Dead  Pulp  Renuiins  in  Tooth 363 

If  Periapical  Tissues  Destroyed  by  Acute  Abscess.  .  .  .  363 

If  Periapical  Tissues  Destroyed  by  Drugs 363 

Detachments  Permanent  and  IMaintain  Chronicity.  .  .  .  363 

Classification   365 

Chronic  Abscess  with  Sinus 365 

Chronic  Abscess  Discharging  Through  Root  Canal.  .  .  .  365 

Blind  Abscess  365 

Chronic  iVbscess  with  Intermittent  Dischai'ge 365 

Variations  in  Positions  of  Sinus  Openings 3()5 

Deposition  of  Subperiosteal  Bone 367 

Deposits  of  Serumal  Calculus 368 

Diagnosis   368 

Pain    368 

Tenderness  of  Tooth 368 

Absorption  of  Bone  and  Loosening  of  Tooth 369 

Pulp  of  Tooth  Dead  or  liemoved 369 

Discharge  of  Pus 369 

Extent   to  Which    Ccmentum    Is   Denuded.      Examinatiim 

with  Steel  Probe 371 

Radiographs 371 


XX  SPECIAL    DENTAL    PATHOLOGY. 

PAGE 

Tkeatment  of  Chkonic  Alveolar  Abscess 373 

Historical 373 

Treatment    375 

Treatment  of  Root  Canal 375 

When  Sinus  Does  Not  Ileal 376 

Cases  of  Blind  Abscess 376 

Practice  in  Vogue  Should  Be  Discontinued 377 

Resection  of  Roots 378 

Technic 378 

Possibilities  of  Healing 378 

Amputation  of  jMolar  Roots 379 

Necrosis  op  the  Maxill.e 380 

Etiology   381 

Symptoms 381 

Treatment    382 

Secure  Good  Drainage 383 

Cleanliness 383 

Extract  Loose  Teeth 383 

Cathartics  and  Anodynes 384 

Removal  of  Sequestra 384 

Prophylaxis  against  Necrosis 386 

Chronic  Osteitis  of  the  Maxill.e 388 

Etiology 388 

Symptoms    389 

Treatment    390 

Epithelial  Cells  of  the  Peridental  jMembrane  in  Relation  to 

Inflammations  and  Cyst  Formation 392 

Studies  by  German  Histo-Pathologists 394 

Cyst  Formation   395 

Systemic  Effects  of  Chronic  Infections  of  the  Mouth 398 

Dr.  Hunter's  Paper  on  Oral  Sepsis 398 

Dr.  Billings'  Investigations 401 

Dr.  Rosenow's  Studies 403 

The  Organism  in  the  Primary  Focus 405 

Three  Groups  of  Chronic  Foci  in  the  Mouth 407 

Defense  by  the  Tissues 408 

The  Dentist's  Opportunity 409 

Summary  409 

Oral  Prophylaxis 411 

General  Prophylaxis   411 

Oral  Prophylaxis  413 


TABLE    OF    CONTENTS.  XXI 

PAGE 

The  Oral  Prophylaxis  Treatment,  So  Called 415 

Application  to  Dental  Caries 416 

Pit  and  Fissure  Decays 417 

Proximal  Decays   418 

Gingival  Third  Decays 419 

Application  to  Diseases  of  the  Peridental  Membrane.  .  420 
Gingivitis  Caused  by  Deposits  of  Salivary  Calculus  420 
Gingivitis  Caused  by  Deposits  of  Serumal  Calculus  421 
Gingivitis  Caused  by  Injuries 421 

Summarj-^   421 

Mouth  Hygiene 423 

Popular  Education 423 

Care  of  the  Mouth 425 

Temporary  Teeth   425 

Teehnic  of  Cleaning  the  Mouth 427 

The  Tooth-brush 427 

Movements  of  the  Brush 429 

Care  of  the  Brush 431 

The  Toothpick   431 

Rubber  Bands  and  Silk  Floss 432 

The  Syringe 433 

When  Gingivae  Are  Inflamed 436 

Mouth  Washes,  Pastes  and  Powders 436 

Dentist  Should  Put  Mouth  in  Condition 437 

When  Cleaning  Should  Be  Done 438 

Training  in  Cleaning  the  Mouth 439 

Artificial  Cleaning  Unnecessary  for  Some  Persons 441 

Irregularities  of  the  Gingivae 442 

Artificial  Dentures    442 

Bridges 445 

Examinations  of  the  Mouth 447 

Routine  Mouth  Examination 448 

Instruments  for  Routine  Examination 450 

General  Survey 451 

Critical  Examination  of  the  Teeth  and  Investing  Tissues.  . .  451 

The  Record  of  the  Examination 456 

The  Examination  Card 4;)7 

Use  of  the  Card 457 

Appendix.    A  Machine  for  Grinding  Microscopic  Specimens 460 

The  Slicing  Machine 461 

The  Grinding  Apparatus 462 

Tho.  Grinding  Disks 464 


Xxii  SPECIAL    DENTAL   PATHOLOGY. 

PAQE 

The  Point  Finder 464 

Lap  Wheels 465 

Grinding  Stones  465 

Watering  the  Stones 465 

Waste  Water 466 

Preparation  of  Material 466 

Management  of  Balsam 467 

Spiders  and  Dogs 467 

Rapidity  of  Grinding 469 

Setting  the  Measurement  of  Grinding  Disks 469 

Grinding  Frail  Material 470 

The  Use  of  Balsam 471 

Removal  of  the  Cover-glass  from  the  Disk 473 

The  Use  of  Shellac 473 

The  Preparation  of  Shellac 474 

Grinding  from  Crumpled  ^Material 474 

Difficulties  in  Grinding 475 


LIST  OF  ILLUSTRATIONS. 


NUMBER 

Investing  Tissues  of  the  Teeth,  Histology  and  Physical  Func- 
tions    1-121 

Gums  and  Gingiv.t, 1-24 

Epithelium 1,  2 

The  various  structures  of  the  investino^  tissues 3 

Diagrams  illustrating  nomenolature  of  the  gingivae 4,  5 

Crest  of  the  alveolar  process 6 

Diagrams  illustrating  groups  of  fibers  in  gingiva*  and  periden- 
tal membrane 7,  8 

Cross  sections  showing  trans-septal  fibers 9,  10 

Diagrams  illustrating  nomenclature  of  the  interproximal  space.  11-14 
Selection  of  teeth  to  show  the  gingival  lines 15-24 

Cementum,  Peridental  IMembrane  and  Alveolar  Process 25-121 

Longitudinal  sections,  deciduous  incisor  and  investing  tissues, 

kitten 25 

Cross  section,  cuspid  and  investing  tissues 26 

Series  illustrating  the  growth  of  connective  tissue 27-42 

Cementum   43-92 

Cross  section,  human  femur,  Haversian  systems 43 

Lengthwise  section  of  same 44 

Bone  in  process  of  absorption 45 

Absorption  of  bone  over  permanent  tooth 46 

Series  illustrating  the  growth  of  bone 47-65 

Absorptions  of  roots  and  repairs  with  cementum 66-74 

Cementum  showing  fibers  of  peridental  membrane 75-78 

Thickness  of  cementum  in  the  young  and  the  aged 79,  80 

ITypercementosis   81-92 

Peridental  Membrane  93-116 

Longitudinal  sections  showing  groups  of  fibers 93-96 

Transverse  sections  showing  fibers 97,  98 

Fibers  of  the  peridental  membrane 99-101 

Cnathodynamometer 102 

The  various  cellular  elements 103-111 

Epithelial  strings 112-116 

(xxiii) 


XXIV  SPECIAL    DENTAL   PATHOLOGY. 

NUMBEK 

Physical  Powers  of  the  Peridental  Membrane  as  Shown  by 

Planted  Teeth 117-119 

Rowlandson's  cartoon,  1787 117 

Radiograph  showing  absorption  of  planted  tooth 118 

Planted  tooth  showing  absorption  of  root 119 

Alveolar  Process 120,  121 

Absorption  of  bone  of  alveolar  process 120,  121 

Investing  Tissues  of  the  Teeth,  Diseases  and  Treatment 122-296 

Studies  of  Salivary  Calculus 122-143 

Denture  with  trap  for  collecting  specimens 122 

Photomicrographs  of  deposits 123-134 

Intubation  of  Stenson's  duct 135-137 

Cheese-like  accumulations  138,  139 

Calculi  removed  from  ducts  of  salivary  glands 140-142 

Calculus  from  human  kidney 143 

Gingivitis   and   Pericementitis   Due   to   Deposits   of    Salivary 

Calculus   144-170 

Colored  drawings  illustrating  progressive  destruction  of  invest- 
ing tissues 144-147 

Teeth  with  deposits  of  salivary  calculus 148-162 

Photomicrograph  of  ground  section  of  deposit  of  salivary  cal- 
culus on  a  tooth 163 

Illustrations  showing  destruction  of  the  investing  tissues.  . .  .164-167 
Deposits  on  artificial  dentures 168-170 

Treatment  of  Gingivitis  and  Pericementitis  Due  to  Deposits  of 

Salivary  Calculus 171-178 

Set  of  sealers 171 

Water  tank  with  thermostat 172 

Electric  thermostat 173-175 

Large  rubber-bulb  syringe 176 

Tablets  for  physiological  salt  solution 177 

Stay  appliance  for  loose  teeth 178 

Gingivitis  Due  to  Deposits  of  Serumal  Calculus 179-185 

Photomicrograph  of  ground  section  of  serumal  calculus 179 

Colored  illustrations  showing  positions  of  deposits  in  subgingival 

spaces    180-182 

Teeth  with  rings  of  serumal  calculus  on  enamel 183-185 

Treatment  of   Gingivitis   Due   to   Deposits   of   Serumal    Cai^- 

cuLus 186-188 

Set  of  Sealers 186 


LIST    OF    ILLUSTRATIONS.  XXV 

NUMBER 

Rubber-bulb  syringe  for  patient's  use 187 

Position  of  nozzle  in  use 188 

Gingivitis  Caused  by  In j  uries 189-215 

Colored  drawings  illustrating  injury  to  the  septal  tissue 189-191 

Plaster    models,    radiographs,    etc.,    showing    injuries    to    the 

gingivae   192-210 

Old  separating  files  and  their  use 211-215 

Treatment  of  Gingivitis  Caused  by  Injuries 216-225 

Testing  contacts,  and  forms  of  contacts 216-218 

Perry  separators  and  their  application 219-225 

Chronic  Suppurative  Pericementitis 226-264 

Colored  illustrations,  showing  gingivitis  and  pericementitis  in 

various  stages 226-231 

Panoramic  radiographs  of  normal  denture ..." 232,  233 

Panoramic  radiographs  of  ease  of  chronic  pericementitis. . .  .234,  235 

Sections  of  normal  peridental  membrane 236,  237 

Photomicrographs  of  tissue  overlying  pus  pockets 238-242 

Radiographs  of  cases  of  chronic  pericementitis 243-252 

Teeth  with  deposits  of  serumal  calculus 253-258 

Photomicrograph  of  ground  section  of  nodule  of  serumal  calculus 

on  a  root 259 

Plaster  model  and  panoramic  radiograph  of  case  of  protrusion 

of  upper  incisors 260,  261 

Models  of  cases  of  lateral  and  septal  abscesses 262,  263 

Drawing  of  pus  pocket  published  in  1886 264 

Treatment  of  Chronic  Suppurative  Pericementitis 265-295 

Instruments  correctly  and  incorrectly  contra-angled 265 

Set  of  scalers 266 

Special  explorers  for  measuring  depth  of  pockets 267 

Series  illustrating  positions  of  scalers  in  use 268-284 

Removal  of  tissue  overlying  pocket 285,  286 

Radiograph  of  case  with  stay  appliance 287 

Radiographs  of  cases  showing  extensive  destruction  of  investing 

tissues 288,  289 

Plaster  models  of  cases  in  which  roots  were  amputated 290-293 

A  surgical  operating-room  bnilt  in  1887 294 

Recent  radiograph  of  elbow  injured  by  gunshot  and  treated  with 

antiseptics  in  1878 295 

Acute  Ulcerous  Gingivitis 296 

Model  of  a  case 296 


XXVI  SPECIAL   DENTAL   PATHOLOGY. 

NUMBER 

Dental  Pulp.     Histology  and  Physical  Functions 297-303 

Sections  showing  cellular  elements 2f>7-299 

Diagram  of  blood  vessels 300 

Photomicrograph  showing  thin  walls  of  l)hi()d  vessels 301 

Odontoblasts  and  dentinal  fibrils 302,  303 

Diseases  of  the  Dental  Pulp 30-4-341 

Hyperemia   3()-4-307 

Sections  showing  changes  in  hyperemia 304-307 

Inflammation   308-316 

Sections  showing  changes  in  inHainmatioii 308-311 

Suppuration,  abscess  and  chronic  inHaminatioti 312-314 

Hypertrophy  of  pulp 315 

Calcifications  in  the  Pulp  Cilvmber 310-341 

Secondary  dentin  resulting  from  erosion 316,  317 

Secondary  dentin  resulting  from  abrasion 318-320.  323-326 

Secondary  dentin  ascribed  to  caries 321-322 

Sections  of  teeth  with  secondary  dentin 327-329 

Atrophy  of  odontoblasts 330,  331 

Pulp  nodules   332-334 

Cylindrical  calcifications  335-337 

Artificially  formed  calco-spherite.s 338,  339 

Calco-spherite-like  forms  in  pulp  and  peridental  membrane. 340,  341 

Technic  of  Treatment  of  the  Dental  Pulp 342-401 

Sterilizing-oven  for  broaches 342 

Operating-tray  equipped  for  pulp  troatme?it 343 

Dish  for  sterilizing  broaches 344 

Dropper  bottle 345,  346 

Photographic    reproductions    showing   effect    of   antiseptics   on 

skin    347-358 

Recessional  lines  of  pupal  horns 359 

Radiographs  of  partially  developed  roots 360-362 

Diagram  showing  contemporaneous  calcification  of  permanent 

teeth   363 

Removing  carious  dentin  in  exposing  pulp 364 

Split  bicuspid  showing  form  of  pulp  chamber 365 

Opening  pulp  chamber  of  central  incisor  from  mesial  or  distal 

surface  366,  367 

Horizontal  .sections  of  upper  first  molars,  showing  forms  of  pulp 

chambers  and  root  canals 368,  369 

Lengthwise  sections  of  upper  molars,  showing  pulp  chambers 

and  root  canals 370-377 


LIST    OF    ILLUSTRATIONS.  XXVll 

NUMBER 

Horizontal   sections  of  lower  molars,  .showing  forms  of  pulp 

chambers  and  root  canals 381 

Lengthwise  sections  of  lower  molars,  showing  pulp  chambers 

and  root  canals 378-380,  382-388 

Position  for  passing  broach  into  canal  of  distal  root  of  any  lower 

molar 389 

Incisor  split  labio-lingually,  showing  method  of  opening  pulp 

chamber  through  lingual  surface 390-393 

Differences  in  shadows-lengths  of  roots  in  radiographs 394-396 

Diagram  showing  progress  of  calcififaiion  of  roots  of  deciduous 

teeth 397 

Diagram  showing  progress  of  absorption  of  roots  of  deciduous 

teeth 398 

Radiograph  showing  failure  of  absorption  of  root  of  deciduous 

tooth  on  account  of  abscess 399 

Kadiograph  and  photographs  showing  roots  of  deciduous  molars 

about  bicuspid  crowns 400,  401 

Acute  Alveolar  Abscess 402-429 

Series  of  colored  drawings  illustrating  acute  and  chi'onic  alveo- 
lar abscess 402-416 

Series  of  radiographs  showing  building  in  of  bone  following  an 

acute  alveolar  abscess 417-422 

Giant  cell  sarcoma,  radiograph  of  case 423 

Cysts  shown  by  tw' o  radiographs  and  a  lower  maxilla 424-426 

Alveolar  abscess  discharging  near  eye 427 

Alveolar  abscess  involving  tissues  of  neck 428,  429 

Chronic  Alveolar  Abscess 430-460 

Lower  jaw  showing  destruction  of  bone  by  abscesses 430-432 

Radiographs  which  emphasize  necessity  of  careful  diagnosis. 433-437 

Radiographs  showing  blind  abscesses 438-441 

Plaster  model  of  abscess  with  intermittent  discharge 442 

Radiographs  of  cases  of  chronic  abscess 443-450 

Deposits   of   .serumal    calculus    on    roots    in    cases    of   chronic 

abscess   451-454 

Root  resection  in  treatment  of  clironic  abscess 455-460 

Necrosis  op  the  Maxill/e 461-463 

Sequestra 461,  462 

Tnvolucrum  causing  facial  deformity 463 

Chronic  Osteitis  of  INTaxill.e 464,  465 

Radiograph  of  a  case 464 

Gilmer's  sharp  stool  ]>robo  and  a  silver  probo 465 


XXViii  SPECIAL   DENTAL   PATHOLOGY. 

NUMBER 

Epithelial  Cells  of  Peridental  Membrane  in  Relation  to 

Inflammations  and  Cyst  Formation 466-476 

Photomicrographs  of  sections  through  cysts  and  cyst  vvmUs.  .466-476 

Mouth  Hygiene 477-500 

Forms  of  tooth-brushes 477-485 

Brushing  the  lower  gingiva?  and  teeth 486-402 

Brushing  the  upper  gingivie  and  teeth 493-497 

Kubber-bulb  syringe  for  washing  interproximal  and  subgingival 

spaces   498 

Brushes  for  artificial  dentures 499,  500 

Examinations  of  the  Mouth 501-507 

Examination  Card  and  plan  of  recording 501-507 

Appendix.    Machine  for  Grinding  Microscopic  Specimens.  . .  .508-518 

Slicing  mechanism 508,  509 

Grinding  mechanism 510-513 

Electric  cut-off 514-516 

Spider  for  mounting  specimens  on  grinding  disks 517,  518 


Special  Dental  Pathology 


INTRODUCTION 

A  STRICTLY  dental  disease  is  one  that  is  peculiar  to  the 
teeth  or  their  membranes,  either  in  its  causation,  its  nature, 
or  in  the  tissues  to  which  it  is  confined,  and  which  can  not  occur 
elsewhere  in  the  body.  The  tissues  of  the  teeth  are,  in  their 
histology  and  physiology,  a  distinct  class.  The  membranes 
investing  the  teeth  have  peculiar  histological  and  physical  char- 
acters and  forms  suited  to  the  functions  of  the  teeth.  These 
form  a  special  assemblage  of  tissues,  the  pathology  of  which  is 
unlike  that  of  any  other  tissues  of  the  body.  It  is  this  special 
pathology,  together  with  the  manipulation  required  in  treatment, 
which  has  made  dentistry  a  specialty  in  medicine. 

I  have  previously  written  a  book  on  the  Pathology  of  the 
Hard  Tissues  of  the  Teeth,  in  which  atrophy  or  hypoplasia, 
erosion,  abrasion  and  caries  were  considered.  In  the  present 
volume  I  shall  include  two  principal  groups:  Diseases  begin- 
ning in  the  gingivae  which  may  in  their  progress  involve  the 
peridental  membrane  and  alveolar  process,  and  diseases  of  the 
dental  pulp  and  their  sequelae,  including  acute  and  chronic  alveo- 
lar abscess,  necrosis,  etc.  It  will  be  found  as  we  proceed  that 
diseases  of  the^ peridental  membrane  occur  as  the  result  of  either 
a  preceding  gingivitis,  which  first  involves  the  peridental  mem- 
brane at  the  gingival  line  of  the  tooth;  or  the  death  of  the  dental 
pulp,  which  first  involves  the  peridental  membrane  at  the  apex 
of  the  root.  From  other  than  these  two  points  of  beginning,  we 
have  practically  no  disease  of  the  peridental  membrane,  except- 
ing as  a  result  of  some  unusual  traumatism.  In  both  groups  we 
are  concerned  with  the  investing  tissues  of  the  teeth,  and  this 
makes  it  especially  advantageous  to  present  a  careful  study  of 
the  physical  functions  of  these  tissues. 

It  is  also  advantageous  to  study  the  pathology  of  these  two 
groups,  as  they  include  practically  all  of  those  foci  in  the  mouth 
which  endanger  tlio  general  health.  In  the  chronic  suj^pura- 
tions  of  the  peridental  membrane  beginning  at  the  gingival  line 


Z  SPECIAL    DENTAL    PATHOLOGY. 

and  in  many  cases  of  chronic  alveolar  abscess,  tlie  investing 
tissues  are  detached  from  the  cementum,  and  in  the  treatment 
of  both  we  are  confronted  with  the  same  problem  of  the  impossi- 
bility of  repair,  due  to  the  peculiar  characteristics  of  the  cemen- 
tum. When  such  detachment  occurs,  the  pus-soaked  cementum 
l)ecomes  practically  a  dead  tissue,  which  can  not  be  exfoliated, 
and  therefore  maintains  the  chronic  focus  indefinitely. 

Recent  investigations  of  the  relationship  of  the;^e  chronic 
foci  to  serious  secondary  lesions,  demand  the  elimination  of 
these  foci,  as  well  as  the  institution  of  more  effective  operating 
for  their  prevention  in  the  future. 

During  practically  the  full  period  of  my  practice,  I  have 
cai-efully  observed  and  recorded  the  i^athological  conditions  of 
tlie  peridental  membrane,  and  for  many  years  these  diseases 
have  been  subject  to  special  study.  During  the  past  few  years 
T  have  devoted  much  time  to  their  consideration,  and  it  is  for  the 
purpose  of  giving  my  findings  to  the  profession  that  this  book  is 
written.  In  fact,  the  ])ublication  of  this  book  has  been  delayed 
in  order  to  carry  on  recent  investigations  of  the  method  of 
deposit  of  calculus,  and  other  matters  which  were  considered 
essential  to  a  proper  presentation. 

A  nomenclature  sufficient  for  a  satisfactory  description 
and  clear  understanding  of  the  various  parts  of  the  gingiva?  and 
peridental  membrane  and  their  functions  has  been  developed. 
Particular  attention  is  given  to  the  various  groups  of  fibers  and 
their  functions  in  maintaining  the  teeth  in  position  under  normrl 
conditions  and  in  tlie  movements  which  result  from  the  cutting 
off  of  certain  groups  of  fibers  by  disease.  Likewise  the  changes 
which  occur  as  a  result  of  suppurative  detachment,  and  the  bear- 
ing which  these  changes  have  on  reparative  processes,  are 
presented. 

Diseases  of  the  peridental  moml)rane  begnnning  at  the  gingi- 
val margins  are  perhaps,  of  all  the  diseases  of  the  dental  tissues. 
the  least  well  understood.  This  is  because  of  an  insufficient 
knowledge  of  the  histology,  ])hvsical  functions  and  special 
})]iysiological  relations  and  dependence  upon  each  other,  of  th" 
tissues  involved,  and  the  failure  to  study  the  local  causes  leading 
to  the  establishment  of  the  disease  by  any  efficient  system  of 
keeping  records  of  cases  in  order  to  note  their  origin  and 
progress.  I  know  of  no  other  group  of  diseases  in  which  such 
a  system  of  study  is  more  necessar>^  to  a  clear  understanding. 

There  has  been  much  confusion  of  ideas  regarding  the 
pathologj"  of  these  diseases.     This  is  largely  because  of  the  slow- 


INTKODUCTTON.  6 

ness  of  their  progress.  We  may  see  cases  wliicli  have  been 
progressing  for  twenty  years,  or  even  longer,  before  they  have 
been  regarded  as  serious,  and  afterward  see  the  complete  wreck 
of  the  denture.  Any  disease  which  progresses  so  slowly  is  espe- 
cially difficult  to  study  in  its  completeness.  It  is  not  like  the 
study  of,  for  instance,  ty})hoid  fever,  in  which  practically  the 
whole  assemblage  of  phenomena  occur  within  three  or  four 
weeks.  One  who  sees  many  cases  of  such  a  disease  comes  soon 
to  know  the  groupings  of  tlie  various  phenomena,  and  to  know 
the  physical  manifestations  of  the  disease  in  all  its  details.  In 
the  acute  form  of  alveolar  abscess  the  case  may  begin  and  run 
its  course  in  from  two  to  six  days,  and  one  easily  gathers  the 
essential  symptoms,  but  in  diseases  of  the  peridental  membrane, 
beginning  at  the  gingival  margin,  in  which  the  rise  and  progress 
usually  extend  over  a  number  of  years,  the  difficulties  are  greatly 
increased. 

The  different  diseases  of  the  gingivae  and  peridental  mem- 
brane, as  well  as  the  various  causes,  are  separately  considered, 
both  as  to  patliology  and  treatment.  It  is  of  the  utmost  impor- 
tance tliat  these  different  conditions  be  recognized  as  a  basis  for 
correct  diagnosis  and  proper  treatment,  although  this  seems  not 
to  have  been  done  by  the  large  majority  of  the  profession.  In 
medicine,  an  accurate  diagnosis  is  the  basis  of  successful  treat- 
ment; it  shouid  be  so  in  dentistry.  The  dentist  wlio  is  able  to 
make  an  exact  and  full  diagnosis  of  the  various  diseases  will 
have  little  difficulty  in  determining  the  best  course  to  pursue  in 
treatment. 

The  names  or  terms  given  to  these  conditions  constitute  one 
of  the  important  features.  These  names  are  all  very  simple 
and  in  each  instance  both  the  cause  and  the  tissue  principally 
involved  are  included.  Such  a  nomenclature  is  essential  to  a 
])roper  undei-standi ng.  Inflammations  involving  the  gingiv;e 
only  are  definitely  separated  from  those  involving  the  peridental 
membrane,  as  a  basis  for  rational  preventive  treatment  of  dis- 
eases of  the  peridental  membrane,  becaur-.e  ging-ivitis  is  a  neces- 
sary antecedent  of  these  diseases.  The  fact  that  deposits  of 
salivary  calculus  destroy  all  of  the  investing  tissues  ^correspond- 
ing to  the  area  of  detachment  from  the  root,  generally  without 
the  formation  of  pus  pockets,  requires  that  the  inflammation 
caused  by  deposits  of  salivary  calculus  be  studied  apart  from 
all  other  inflammations  of  the  investing  tissues. 

Studies  of  the  deposit  of  salivary  calculus  have  shown  that 
the  calcium  element  is  brought  into  the  mouth  with  the  saliva  in 


4  SPECIAL   DENTAL   PATHOLOGY. 

the  form  of  calco-globulin ;  also  that  the  deposits  are  paroxys- 
mal in  character  and  of  comparatively  short  duration  at  rather 
definite  periods  after  meals.  These  studies  indicate  that  the 
outpouring  of  calco-globulin  results  from  digestion  in  excess  of 
assimilation.  Calco-globulin  has  been  obtained  from  the  saliva, 
also  direct  from  Stenson's  duct,  and  the  specimens  have  been 
stained  and  photogTaphed.  Deposits  occurring  in  the  mouth,  on 
traps  constructed  for  the  purpose,  have  been  examined  and 
photographed  during  all  stages  from  the  initial  soft  to  the  stony 
hard  deposits.  By  a  specially  designed  lathe  for  grinding 
microscopical  sections  of  hard  substances,  the  deposits  of  both 
salivary  and  serumal  calculus  upon  the  teeth  have  been  studied 
and  photomicrographs  made  which  were  not  heretofore  possible. 
These  studies  have  indicated  a  thoroughly  dependable  system  of 
treatment  for  prevention  or  control  of  the  destructive  inflamma- 
tions resulting  from  deposits  of  salivarj^  calculus. 

In  the  study  of  the  chronic  suppurative  detachments  of  the 
peridental  membrane,  in  which  pus  pockets  are  formed,  it  will  be 
shown  that  deposits  of  serumal  calculus  upon  the  cementum  are 
never  a  primary  cause  of  these  pockets.  Practically  all  cases 
may  be  accounted  for  as  due  to  local  causes,  the  treatment  of 
which  is  usually  simple,  offering  the  key  to  effective  prevention 
of  this  most  destructive  of  mouth  diseases,  which  is,  of  the  mouth 
infections,  the  greatest  menace  to  the  general  health. 

In  the  consideration  of  the  dental  pulp,  enough  of  the  histol- 
ogy and  physiological  functions  will  be  given  to  enable  the 
reader  to  gain  the  best  understanding  of  the  diseases  of  this 
tissue.  It  will  be  noted  that  the  classification  of  these  diseases 
is  based  upon  the  clinical  manifestations,  rather  than  upon 
microscopical  examinations  which  can  not  be  satisfactorily 
applied  in  practice. 

Radiography  has  enabled  us  to  make  much  more  accurate 
diagnoses  of  conditions  within  the  maxillary  bones  than  was 
possible  previous  to  its  use.  The  employment  of  the  radiograph 
in  the  examination  of  cases  of  chronic  suppurative  pericemen- 
titis shows  clearly  the  progressive  absorption  of  the  alveolar 
process  subsequent  to  detachments  of  the  peridental  membrane 
from  the  cementum.  The  showing  of  cavities  within  the  bone 
about  the  ends  of  roots,  following  pulp  treatment  in  a  very  con- 
siderable percentage  of  cases,  brings  home  the  importance  and 
absolute  necessity  for  more  careful  technic  and  greater  thor- 
oughness  in  the   handling  of  root  canals.     This   should   also 


INTRODUCTION".  5 

impress  the  need  for  more  accurate  diagnoses  of  pulp  conditions 
and  less  of  recklessness  in  pulp  destruction. 

This  book  is  essentially  a  work  on  preventive  treatment. 
For  practically  every  pathological  condition  discussed,  the  possi- 
bilities and  methods  of  prevention  are  presented.  The  special 
aim  has  been  to  point  out  the  value  in  prevention  of  a  closer  study 
of  the  patholog}'^,  in  order  that  careful  observation  and  prompt 
recognition  of  the  beginnings  of  these  diseases  will  lead  to  better 
judgment  and  greater  care  in  the  finer  details  of  manipulation  in 
all  operations  performed.  Effective  prophylaxis  against  the  dis- 
eases of  the  investing  tissues  can  not  result  from  the  so-called 
oral  prophylaxis  treatments ;  this  must  be  brought  about  by  the 
practice  of  prophylactic  dentistry,  in  which  the  effect  of  every 
operation  in  preventing  or  causing  disease  will  be  appreciated. 

The  place  which  the  so-called  oral  prophylaxis  treatment 
should  occupy  in  practice  will  be  stated.  The  necessity  for  the 
careful  training  of  patients  in  mouth  hygiene  will  be  presented 
as  an  important  element  in  the  preventive  and  palliative  treat- 
ment of  most  of  the  diseases  considered.  A  separate  chapter  is 
devoted  to  the  subject  of  mouth  hygiene. 

More  rational  medication  than  now  generally  practiced  is 
strongly  urged.  This  applies  particularly  to  the  use  of  caustics 
and  antiseptics  in  the  treatment  of  both  the  peridental  membrane 
and  dental  pulp.  The  tendency  of  surgeons  toward  the  aban- 
donment of  antiseptics  in  the  treatment  of  wounds,  on  account 
of  the  effect  of  these  in  interfering  with  the  activity  of  the 
tissues,  should  lead  us  to  a  similar  course. 

Conditions  in  the  mouth  are  such  that  it  is  impossible  to 
maintain  asepsis.  This  fact,  coupled  with  the  fact  that  detach- 
ments of  the  peridental  membrane  from  the  cementum  produce 
a  constantly  acting  irritant,  place  these  diseases  in  a  class  to 
themselves,  entirely  different  from  suppurations  which  occur 
elsewhere  in  the  body.  In  treatment  we  should  appreciate  the 
exceptional  powers  of  the  mouth  tissues  in  combating  infections 
and  should  encourage  them  by  maintaining  the  limit  of  cleanli- 
ness, rather  than  hinder  them  by  the  use  of  drugs  which  inter- 
fere with  their  activities. 

In  the  consideration  of  so  many  closely  related  conditions, 
numerous  duplications  of  statements  occur.  After  a  review  of 
the  completed  text,  it  seems  desirable,  for  the  fullest  understand- 
ing of  each  subject,  that  these  repetitions  remain. 

Practically  all  of  the  illustrations  are  original.  A  consid- 
erable number  are  reproduced  from  my  previous  writings  in  the 


6  SPECIAL   DENTAX.  PATHOLOGY. 

American  System  of  Dentistry  and  my  own  books  and  articles 
in  dental  journals.  Others  have  been  prepared  especially  for 
this  book. 

A  lathe  designed  and  constructed  for  the  purpose  of  grind- 
ing microscopical  sections  of  hard  substances,  such  as  teeth, 
deposits  of  calculus,  etc.,  is  illustrated  and  described  in  the 
appendix. 


INVESTING   TISSUES,   HISTOLOGY,   PHYSICAL   FUNCTIONS. 


THE    INVESTING  TISSUES   OF   THE   TEETH 
GINGIVAE,    PERIDENTAL   MEMBRANE, 
GEMENTUM  AND  ALVEOLAR  PROCESS 


HISTOLOGY  AND  PHYSICAL  FUNCTIONS 


THE  GUMS  AND  GINGIVAE 

ILLUSTRATIONS:    FIGURES  1-24. 

THE  gums  clothe  the  alveolar  processes  and  the  hard  palate, 
and  the  gingivae  invest  the  gingival  portions  of  both  the 
roots  and  crowns  of  the  teeth.  These  divisions  of  tissue  join 
each  other  by  continuity  without  apparent  demarcation  at  the 
crest  of  the  alveolar  process.*  That  is,  there  is  nothing  on  the 
surface  to  indicate  a  change  in  the  character  or  quality  of  the 
tissue.  But  at  this  point  the  soft  tissue  at  once  passes  across 
between  the  adjoining  teeth,  through  each  interproximal  space, 
and  joins  together  the  soft  tissues  covering  the  buccal  and  labial 
parts  with  the  lingual  parts,  and  surroimds  each  tooth.  In 
doing  this  the  teeth  are  completely  invested  with  a  soft  tissue 
alveolar  process.  If  this  tissue  were  dissected  away  from  the 
bony  alveolar  process  and  the  teeth  smoothly  removed,  it  would 
consist  of  a  considerable  piece  of  tissue  reaching  around  the 
arch,  including  the  third  molar  on  each  side,  through  which  there 
would  be  a  hole  (alveolus)  corresponding  to  each  tooth.  While 
these  divisions  of  tissue  have  much  in  common  in  their  histo- 
logical make-up,  the  gingiva)  have  tissue  characters  and  func- 
tions not  possessed  by  the  gums.  It  therefore  seems  best  to 
describe  the  characters  common  to  both  first,  and  then  under  the 
more  specific  definitions,  to  describe  the  gingivae. 

The  gums  consist  of  soft  tissue  noted  for  its  compact  inelas- 
tic firmness,   which  spreads  from  the  crests   of  the  alveolar 

*  While  I  have  long  considered  the  above  the  proper  line  of  division  between  the 
gums  and  gingivae,  I  have  not  heretofore  had  the  courage  to  include  so  much  tissue 
under  the  name  of  the  gingiva?;  but  when  I  undertake  to  write  a  full  description  of 
these  tissues,  it  seems  absolutely  necessary  that  the  division  bo  so  made,  because  the 
crest  of  the  alveolar  process  marks  the  logical  boundary  of  the  gingival  covering  of 
the  teeth. 


8  SPECIAL    DENTAL    PATHOLOGY. 

processes  and  covers  the  alveolar  ridges  well  down  and  away 
from  the  teeth  in  all  directions.  Then  a  change  in  character  to 
a  soft  mucous  membrane  occurs,  which  is  reflected  on  the  labial 
and  buccal  portions  as  the  mucous  membranes  of  the  lips  and 
cheeks  from  both  the  upjier  and  lower  arches.  On  the  lingual 
side  of  the  lower  jaw  it  is  much  the  same,  the  hard  portions  pass- 
ing into  the  soft  flexible  mucous  membrane  of  the  floor  of  the 
mouth.  In  the  upper  jaw  the  dense  membrane  spreads  over  the 
entire  i)alatal  surface,  back  as  far  as  the  junction  of  the  hard 
and  soft  palate.  This  hard  inelastic  tissue  is  known  as  the 
gums.  Curiously  enough,  the  plural  foiTa  of  the  word  is  gener- 
ally used,  though  the  singular,  gum,  will  be  heard  occasionally 
when  the  reference  is  to  some  particular  spot.  We  also  say  gum 
tissue,  and  use  the  singular  form  in  other  such  combinations. 

The  fibrous  mat. 

The  basis  of  the  gum  tissue  is  a  thick  mat  of  inelastic  fibers. 
Many  of  these  fibers  are  large  and  are  branched  and  connected 
in  every  direction  in  rather  short  lengths,  forming  a  dense  net- 
work, or  mat.  The  periosteum,  which  is  very  firmly  attached  to 
the  bone  over  this  region,  is  also  veiy  closely  interwoven  with 
this  fibrous  network.  In  this  union  the  two  tissues  retain  their 
identity.  That  is,  the  periosteum  retains  its  usual  closely 
coherent  form,  and  the  fibrous  mat  of  the  gum  tissue  also 
retains  its  form,  but  the  two  are  so  united  by  interlocking  of 
fibers  as  to  prevent  sliding  movements  of  the  one  upon  the  other 
or  upon  the  bone.  This  gives  the  parts  their  characteristic 
hardness  and  immobility. 

One  should  have  a  clear  understanding  of  the  difference 
between  such  an  immobile  tissue  and  a.  very  mobile  tissue.  If 
two  fingers  of  one  hand  are  placed  on  the  back  of  the  other  hand 
crosswise,  and  if,  while  pressing  firmly,  the  fingers  are  moved  as 
far  as  the  sliding  of  the  skin  will  allow  and  the  skin  moved  back 
and  forth,  it  will  be  noticed  that  it  will  slide  considerably.  This 
will  differ  much  in  different  individuals;  in  some  it  will  move  an 
inch  or  more,  in  others  less.  The  so-called  i)ulps  of  the  palmar 
surfaces  of  the  fingers  are  rather  soft  masses  of  tissue.  If  the 
pulps  of  the  two  middle  fingers  are  placed  together  and  moved 
upon  each  other  with  firm  pressure,  it  will  be  noticed  that  this 
tissue,  while  soft  and  elastic,  is  comparatively  immobile  —  much 
more  immobile  than  the  skin  on  the  back  of  the  hand.  The  gums 
are  generally  immobile.  To  demonstrate  this,  one  may  dry  any 
part  of  the  gums  with  a  napkin  and  place  the  dry  finger  upon  this 


Fig.  1. 


Fio. 


FlO.  1.  Stratified  squamous  epithelium  covering  tlie  alveolar  process:  c,  Corne- 
ous layer,     p,  Papilla  of  connective  tissue.     Noyes. 

Fig.  2.  Stratified  squamous  epithelium  from  unattached  mucous  membrane  of 
the  mouth.     The  corneous  layer  is  absent.     Noyes. 


*1 


Fig.  3. 


Fig.  :{.  Loiif^ilinlinal  soction  thiougli  the  giii>ii\;i  !iii<l  the  giujjivul  portion  of  the 
peridental  membrane.  E,  Epithelium,  d.  Dentin,  c,  Cementum.  s.  Subgingival 
space.  F,  Free  gingiva?;  group  of  fibers,  a,  Alveolar  crest  group  of  fibers.  H,  Hori- 
7ontal  groii|)  of  fibers.     B,  Brne  of  alveolar  ])ropess.     \oyes. 


Fig.  4. 


Figs.  4  and  5.     Diagrams  illustrating  noiiUMiclatiirc  of  gingiva". 

Fig.  4.  Bucco-lingnal  section  through  tooth  and  investing  tissues.  A,  Alveolar 
process,  a',  Crest  of  alveolar  process,  g,  (Jum.  B.  Body  of  gingiva.  F,  Free 
gingiva,     c,  Crest  of  gingiva,     sg.  Subgingival  space. 

Fig.  •').  Mesio-distal  section  through  first  and  second  bicuspids  and  septal  tissue. 
A,  Alveolar  process,  a',  Crest  of  alveolar  process.  B,  Body  of  gingiva,  s.  Septal 
gingiva,  c.  Crest  of  septal  gingiva  just  below  contact  ])oint.  sg,  sg.  Subgingival 
spaces. 


'% 


Fig.  6. 


Fig.  6.  Crest  of  the  alveolar  wall,  from  a  perpendicular  section,  a,  Haversian 
bone,  which  is  left  without  stippling  to  render  it  more  apparent,  b.  Subperiosteal 
bone,  showing  residual  fibers,  e.  F'eriosteuni.  d.  Extreme  crest  of  the  alveolar  wall. 
e,  Fibers  of  the  peridental  membrane,  f,  Bone  formed  by  the  osteoblasts  of  the 
peridental  membrane,     g.  g,  g,  Points  at  which  the  absorption  of  bone  is  in  progress. 


INVESTING    TISSUES,    HISTOLOGY,    PHYSICAL    FUNCTIONS.  9 

spot,  and  try  to  move  the  tissue  upon  itself.  One  can  not  slide 
it  at  all.  This  explanation  will  give  a  full  understanding  of 
what  is  meant  by  the  statement  that  the  gum  tissue  is  immobile. 
This  quality  of  the  tissue  is  so  characteristic  that  it  can  not  be 
missed  in  any  examination  of  the  regions  named.  These  char- 
acteristics extend  to  the  gingivae  in  most  of  their  parts,  and  may 
be  said  to  be  common  to  the  two  divisions  of  tissue. 

Epithelium. 

The  whole  of  this  region  has  a  covering  of  strong  pavement, 
or  squamous  epithelium.  (See  Figures  1,  2  and  3.)  In  most 
parts  the  tissues  beneath  are  quite  closely  interdigitated  into 
this  epithelium,  giving  it  a  very  firm  hold,  so  that  it  is  not  easily 
scraped  away.  This  epithelium  has  an  especially  strong  growth 
and  the  surface  cells  are  continually  being  shed  away  to  give 
place  to  new  superficial  cells.  These  cast-off  cells  will  be  found 
liberally  distributed  in  every  specimen  of  the  mixed  saliva  taken 
from  the  mouth. 

Blood. 

The  blood  vascular  system,  as  everywhere  in  the  mouth,  is 
rich,  and  especially  so  in  the  capillary  circulation.  The  blood 
vessels  will  be  found  everywhere  in  the  tissue,  winding  in  every 
direction  among  the  interlacing  white  fibers.  Accompanying  the 
blood  vessels,  there  are  a  smaller  number  of  softer  connective 
tissue  fibers  and  cells  filling  in  the  interstices  of  the  coarser 
fibrous  mat. 

Sensation. 

The  nerve  supply  is  good,  but  the  tissue  is  generally  not 
very  sensitive  to  painful  impressions,  though  its  sense  of  touch 
is  fairly  good.  Its  lack  of  sensitiveness  to  pain  that  would  ordi- 
narily be  caused  by  the  forcible  movements  of  rough  material 
over  it  is  very  striking  when  it  is  in  normal  condition.  This  is 
one  of  the  curious  phenomena  of  nature,  stipulated  and  arranged 
for  a  purpose.  This  tissue,  richly  endowed  with  blood  and 
nerves,  lies  on  a  surface  where  foreign  substances  are  very 
frequently  in  contact  with  it,  and  yet  as  compared  with  most 
of  the  other  tissues,  it  is  markedly  insensitive  to  these.  The 
gingivae  have  the  same  characteristics  in  all  of  their  parts. 

Why  is  it  that  this  tissue  is  so  insensitive  to  painful  impres- 
sions? This  is  one  of  the  very  inconsistent  things,  at  first 
thought,  which  becomes  physiologically  consistent  when  rightly 


10  SPECIAL   DENTAL   PATHOLOGY. 

understood.  These  are  defensive  tissues,  hard  and  rugged,  not 
easily  torn,  bruised  or  lacerated,  placed  on  either  side  of  the 
dental  arches  and  wound  everywhere  about  the  teeth.  If  these 
tissues,  even  though  hard,  were  very  sensitive,  as  their  blood 
supply  and  their  nerve  supply  would  lead  us  to  infer,  we  would 
be  in  pain  from  scrapings  of  many  of  the  foods  we  chew  and 
force  harshly  over  their  surfaces.  Their  hardness,  which  saves 
them  from  real  injury,  and  their  insensitiveness  to  pain,  protects 
us  from  painful  experiences  in  chewing  food.  This  explains  the 
physiological  provision,  and  the  necessity  for  it. 

If  we  compare  this  insensitiveness  of  the  membranes  of  the 
mouth  with  the  extreme  sensitiveness  of  the  membranes  of  the 
eye,  we  will  appreciate  the  diiferences  in  the  endowments  as 
to  sensation  given  to  different  tissues  to  effect  physiological 
purposes.  The  uses  of  the  eye  require  the  most  perfect  cleanli- 
ness of  its  surfaces.  This  is  provided  for  by  the  lacrimal  fluid 
poured  over  the  surfaces  to  wash  them,  and  the  movements  of 
the  lids  to  prevent  stagnation.  The  sensitiveness  is  so  great  that 
if  the  smallest  mote  sticks  fast  and  will  not  move  out,  pain  is 
promptly  felt.  This  comparison  should  serve  to  impress  the 
fact  that  the  different  tissues  are  differently  endowed,  as  to 
sensation,  and  in  many  other  ways,  to  effect  physiological 
purposes. 

Particular  attention  is  called  to  the  fact  that  this  very 
insensitive  tissue  may  be  aroused  into  extreme  sensitiveness 
(hypersensitiveness),  especially  by  those  conditions  in  which  it 
is  continually  prodded  and  irritated.  We  often  see  this  promi- 
nently manifested  at  points  upon  which  a  plate  for  artificial 
teeth  binds  too  hard  and  is  frequently  being  moved,  or  is  work- 
ing back  and  forth.  Such  points  are  particularly  apt  to  become 
angry  (if  I  may  use  the  word  in  such  a  connection)  and  complain 
bitterly  of  every  interference.  We  may  also  find  very  consid- 
erable sensitiveness  aroused  in  cases  of  inflammation  of  the 
gums,  and  not  very  infrequently  during  the  inflammatory  process 
of  the  pointing  of  an  alveolar  abscess.  Many  other  conditions 
will  bring  about  similar  results. 

After  all  is  said,  we  should  still  remember  that  under  all 
ordinary  conditions  the  principal  function  of  the  gum  tissue  is 
defensive.  It  is  not  very  subject  to  diseases  except  as  these 
spread  to  it,  or  are  communicated  by  disease  of  contiguous  parts. 
It  is  not  a  tissue  which  in  general  requires  much  attention  from 
the  dentist. 


the  gingiva.  11 

Healing  powers. 

In  spite  of  the  hardness  and  rigidity  of  the  gum  tissue,  it 
will  sometimes  be  lacerated  in  the  crushing  of  hard  substances 
over  it.  The  rich  blood  and  nerve  supply  is  at  hand  to  mend 
such  breaks  in  the  most  speedy  manner  possible.  Further,  the 
nature  of  the  tissue  itself  as  to  its  inflexibility  is  such  as  to  hold 
the  parts  in  apposition  instead  of  allowing  them  to  spread  apart, 
as  most  of  the  soft  tissues  are  inclined  to  do  when  cut  or  torn. 
In  this  respect  this  tissue  reminds  one  of  soft  vulcanizable  rubber. 
If  a  knife  cut  is  made  in  a  bit  of  this  soft  rubber,  the  parts  imme- 
diately return  to  apposition.  This  tendency,  only  somewhat  less 
marked,  will  be  found  in  the  gum  tissue,  but  has  its  greatest 
development  in  the  gingivae.  This  in  itself  contributes  to  very 
certain  and  rapid  healing  of  small  wounds. 

In  larger  injuries,  especially  when  the  tissue  has  been  torn 
away  from  the  bones,  we  may  find  an  opposite  tendency  —  that 
is,  to  curl  away.  There  are  conditions  of  inflammation  and 
swelling,  which  tend,  for  the  time,  to  obliterate  these  characters. 
But  even  in  the  lancing  of  acute  alveolar  abscess,  where  the 
tissues  are  inflamed  and  swollen,  and  where  considerable 
amounts  of  pus  are  discharged  through  the  lips  of  the  cut,  I  have 
seen  the  cut  surfaces  united  within  six  hours.  It  is  never  safe 
to  leave  such  a  case  after  the  evacuation  of  the  pus,  especially 
if  more  pus  may  be  expected,  without  something  in  the  wound 
to  prevent  it  from  closing  too  quickly. 

The  Gingiva. 

ILLUSTRATIONS:    FIGURES  3-24, 

The  word  gingiva,  plural  gingivae,  is  derived  from  the  Latin 
word  gigno,  which  means  to  be  born,  to  spring,  to  arise,  and  is 
applied  to  that  portion  of  the  gum  tissue  through  which  the 
tooth  erupts,  and  later  to  that  soft  tissue  immediately  encircling 
the  tooth. 

That  division  of  the  tissues  of  the  mouth  which  we  call  the 
gingivae  comprises  the  soft  tissue  which  rests  upon  the  crests  of 
the  alveolar  process,  including  the  crests  of  the  septi  which  pass 
between  the  teeth,  invests  the  gingival  portions  of  the  roots  of 
the  teeth  and  rises  about  the  gingival  portions  of  their  crowns. 
(See  Figure  3.)  This  division  of  the  soft  tissue  is  connected 
directly  by  the  fibers  of  the  peridental  membrane  to  the  roots 
of  the  teeth  from  the  level  of  the  crest  of  the  alveolar  process, 


12  SPECIAL.   DENTAL   PATHOLOGY. 

including  the  bony  septi,  to  the  gingival  lines  upon  the  teeth. 
At  the  crest  of  the  alveolar  process  on  the  buccal,  labial  and 
lingual,  the  gingivae  join  with  the  gum  tissue  without  demarca- 
tion. They  also  rise  about  the  teeth  from  the  attachment  at  the 
gingival  line,  in  a  free  border  passing  completely  around  each 
tooth  and  covering  more  or  less  of  the  gingival  portion  of  the 
enamel  surface  of  the  crown.  When  in  full  and  undisturbed 
health,  this  free  border  thins  away  to  a  knife-edge  that  lies  verj^ 
close  against  the  surface  of  the  enamel,  but  may  readily  be 
lifted  from  the  enamel  with  a  very  thin  flat  instrument,  disclos- 
ing the  subgingival  space  between  this  free  border  and  the  tooth. 

The  large  number  of  fibers  of  the  character  of  those  of  the 
peridental  membrane  received  into  the  gingival  tissues  from 
these  several  sources,  and  possibly  others  of  like  character  and 
qualities  developed  in  the  tissue  itself,  serve  to  differentiate  its 
histological  characters  from  those  of  the  general  gum  tissue.  The 
coarser  fibrous  mat  from  the  gum  tissue  continues  into  the 
gingivfp,  but  becomes  finer  and  more  closely  woven  and  is 
reduced  in  proportional  amount.  While  the  general  character 
of  the  tissue  continues  to  be  fibrous,  there  is  in  the  gingivae  a 
larger  i^roportion  of  cellular  elements  and  blood  vessels,  and  the 
tissue  seems  softer.  Yet  in  any  effort  to  move  it  or  slide  it  upon 
itself,  upon  the  bone,  or  upon  the  teeth,  it  is  found  to  be  practi- 
cally immobile  in  any  direction.  It  shows  still  more  of  the  soft, 
rubber-like  tendency  to  return  its  parts  into  apposition  when 
cut,  than  has  been  mentioned  in  describing  the  gums.  This  very 
remarkable  tendency  facilitates  the  process  of  the  healing  of 
cuts  and  scratches  of  its  surface  in  the  most  powerful  way. 

Among  the  tissues  of  the  mouth,  the  gingivae  stand  out  in 
importance  because  of  the  fact  that  this  tissue  is  the  place  of 
beginning  of  serious  diseases,  which  are  attracting  more  and 
more  attention  from  the  better  men  in  dentistry,  general  medi- 
cine and  surgery,  and  from  many  intelligent  la>Tnen  as  well. 
Up  to  the  present  time  there  has  been  surprisingly  little  study 
of  these  tissues  in  their  healthy  state,  or  of  their  functions  or 
their  physiological  relations  to  the  teeth  and  surrounding  parts. 
What  study  has  been  given  them,  has  been  mostly  of  the  empiri- 
cal sort,  or  clinical  studies  that  have  not  followed  individual 
cases  from  early  enough  in  their  beginnings,  nor  long  enough  in 
their  progress,  to  obtain  the  best  results  as  studies  of  pathology. 

For  these  reasons,  every  part  of  this  tissue,  as  it  appears  in 
health,  should  be  studied  both  anatomically  and  physiologically 
as  closely  as  possible,  with  our  present  means.     Even  to-day, 


THE    GINGIVAE.  13 

any  one  who  undertakes  this  study  will  find  the  literature  very 
scant  of  facts  bearing  upon  this  particular  subject.  I  shall  be 
compelled  to  depend  very  largely  upon  my  personal  studies  for 
what  I  may  present. 

PARTS    OF    THE    GINGIVA. 

The  parts  of  the  gingivae  are  the  body,  the  free  gingivce  and 
the  septal  gingivce.  The  body  consists  of  that  tissue  which  rests 
on  the  bony  alveolar  process,  and  forms  a  soft  tissue  extension 
of  the  alveolar  process  as  far  as  the  gingival  line  of  the  teeth. 
The  free  gingivae  and  the  septal  gingivae  consist  of  that  tissue 
which  is  grown  upon  the  body,  which  encircles  the  gingival 
portion  of  the  enamel  of  the  crown  of  each  tooth.  Toward  the 
occlusal,  the  free  gingivie  thin  down  to  a  knife-edge  margin, 
which  I  shall  generally  call  the  crest  of  the  gingiva?.  (See 
Figures  4  and  5.) 

The  free  gingivae  may  be  conveniently  divided  into  parts  by 
naming  the  parts  of  the  crown  of  the  tooth  against  which  they 
are  imposed;  viz.,  the  buccal  gingivce,  the  labial  gingivce,  the 
"Ungual  gingivce.  Those  portions  which  occupy  the  interproxi- 
mal spaces  are  the  septal  gingivce.  The  term  subgingival  space 
is  given  to  the  space  between  the  free  gingiva  and  the  enamel 
which  it  covers. 

The  body  of  the  gingiva. 

The  body  is  attached  to  the  gums  by  continuity  of  tissue  on 
the  labial,  buccal  and  lingual  sides  of  the  teeth ;  and  to  the  bony 
alveolar  process  by  the  fibers  of  its  periosteum.  It  is  attached 
by  the  fibers  of  the  peridental  membrane  to  the  gingival  portion 
of  the  roots  of  the  teeth  from  the  level  of  the  crest  of  the  bony 
alveolar  process  to  the  gingival  line.  This  attachment  to  the 
root  is  on  the  average  about  two  millimeters  in  width,  encircling 
the  root. 

The  fibers  of  the  periosteum  are  short  and  their  identity  is 
quickly  lost  in  the  formation  of  a  dense  membrane,  to  which  the 
superimposed  tissue  is  united.  (See  Figure  G.)  In  any  certain 
regions  (except  those  of  the  actual  attachment  of  tendons  directly 
to  the  bones)  in  which  strong  attachments  are  to  be  made  to  the 
bones  by  attachment  to  the  periosteum,  the  periosteum  forms  a 
membranous-like  layer  in  that  part  of  its  thickness  farthest  from 
the  bone,  or  in  its  outer  layers,  as  op])osed  to  the  inner  layers 
which  lie  u])on  the  ])one.  Nearly  all  of  the  muscles  which  are 
attached  directly  without  tendons,  are  united  to  such  a  layer  of 


14  SPECIAL   DENTAL   PATHOLOGY. 

the  periosteum.  I  have  found  this  form  of  the  periostemn  com- 
mon about  the  crests  of  the  alveolar  processes.  On  the  other 
hand,  the  fibers  of  the  peridental  membrane  of  this  region  are 
long  and  much  in  evidence  in  properly  stained  microscopic 
sections. 

In  these  attachments  the  periosteum  retains  its  character  of 
close  adhesion  to  the  bone  as  described  above,  and  unites  sud- 
denly, but  very  firmly,  with  the  other  tissue,  so  that  there  is  not 
much  spreading  of  fibers  from  it.  The  peridental  membrane 
continues  without  change  of  form  in  the  portions  next  to  the 
cementum  to  the  limits  of  its  attachment  at  the  gingival  line. 
In  this  part  of  the  peridental  membrane  the  fibers  are  very 
plentiful,  thick  and  strong.  They  radiate  in  part  to  the  crest  of 
the  bony  alveolar  process,  and  in  part  to  the  soft  tissues. 

Groups  of  fibers  in  the  GiNGiviE  and  peridental  membrane. 

The  fibers  of  the  peridental  membrane  form  certain  rather 
definite  groups,  in  addition  to  which  there  are  many  scattering 
fibers.  All  of  the  groups,  in  both  the  gingivae  and  peridental 
membrane,  which  deserve  special  description,  will  be  mentioned 
here,  in  order  that  their  relationship  may  be  understood.  Begin- 
ning with  those  fibers  attached  to  the  cementum  at  the  gingival 
line  of  the  tooth  and  progressing  toward  the  apex  of  the  root,  we 
find  the  following  groups : 

The  free  gingiva  group,  consisting  of  those  fibers  which 
pass  out  from  the  cementum  near  the  gingival  line  of  the  tooth 
and  then  extend  occlusally  into  the  free  gingivae. 

The  trans-septal  group,  consisting  of  those  fibers  which  pass 
across  the  interproximal  space,  connecting  the  proximal  sur- 
faces of  the  roots.  Their  attachment  to  the  roots  being  between 
the  gingival  line  and  the  level  of  the  crest  of  the  bony  alveolar 
septum. 

The  alveolar  crest  group,  consisting  of  those  fibers  which 
pass  out  into  the  body  of  the  gingivae  and  are  attached  to  the 
crest  of  the  bony  alveolar  process. 

The  horizontal  group,  consisting  of  those  fibers  which  pass 
out  at  right  angles  to  the  long  axis  of  tlie  tooth  and  are  attached 
to  the  bone  of  the  alveolar  process  a  little  below  the  crest. 

The  oblique  group,  consisting  of  those  fibers  which  pass 
from  the  cementum  in  an  oblique  direction  occlusally,  and  are 
attached  to  the  bone  of  the  alveolar  process.  These  oblique 
fibers  constitute  the  body  of  the  peridental  membrane,  or  the 
fibers  which  cover  the  main  body  of  the  root  portion  of  the  tooth. 


THE    GINGIViE.  15 

The  apical  group,  consisting  of  those  fibers  which  are 
attached  about  the  apical  portion  of  the  root  and  extend  in  fan- 
shaped  bundles  to  the  surrounding  alveolar  process. 

The  free  gingivas  group,  the  trans-septal  group  and  the 
alveolar  crest  group  extend  within  the  gingivae,  while  the  hori- 
zontal group,  the  oblique  group  and  the  apical  group  are  within 
the  bony  alveolus. 

The  free  GiNcrvjE  group.  The  fibers  of  this  group  extend 
outward  for  a  short  distance  from  the  cementum,  and  then  turn 
occlusally  and  are  distributed  to  the  free  gingivae.  This  group 
of  fibers  encircles  the  tooth  completely,  but  is  much  thicker  and 
stronger  on  the  labial,  or  buccal,  and  lingual  than  on  the  proxi- 
mal surfaces.  As  seen  in  longitudinal  labio-lingual  (or  bucco- 
lingual)  sections  cut  through  the  tooth  and  its  investing  tissues, 
it  is  a  small,  rather  thick  tuft  of  fibers  turning  toward  the  incisal 
(or  occlusal),  but  if  we  consider  the  entire  circumference  of  the 
tooth,  the  fibers  of  this  group  make  up  quite  a  mass  of  tissue, 
contributing  to  the  rigidity  of  the  gingivae.  It  is  the  smallest 
of  the  groups  of  the  gingival  fibers  of  the  peridental  membrane. 
This  group  probabl}^  has  a  considerable  influence  in  maintaining 
the  free  gingivae  in  their  positions  of  close  adaptation  to  the 
teeth.     (See  Figures  3,  7  and  8.) 

The  trans-septal  group.  The  fibers  of  this  group  arise 
from  the  proximal  surfaces  of  the  gingival  portion  of  the  roots 
of  the  teeth,  and  pass  across  and  through  the  septal  gingivae  over 
the  bony  septum  from  tooth  to  tooth,  and  from  tooth  to  tooth, 
recurring  in  each  interproximal  space,  attaching  the  teeth 
together  continuously  from  one  third  molar  around  the  arch  to 
the  third  molar  of  the  opposite  side,  in  both  upper  and  lower 
arches.  In  a  good  many  instances  this  group  of  fibers  is  com- 
posed of  a  number  of  bands  which  pass  irregularly  across  from 
tooth  to  tooth.  These  are  sometimes  intermingled  in  a  plaited 
or  interwoven  form.  In  studying  these,  it  seems  that  they  are 
capable  of  making  the  pull  as  well  as,  or  better  than,  those  which 
pass  directly  from  one  tooth  to  another  in  a  straight  line.  The 
effect  of  these  fibers  is  to  bind  the  teeth  more  firmly  together  in 
the  mesio-distal  direction  and  especially  to  hold  the  contacts  of 
the  teeth  tight. 

In  histological  sections  which  are  cut  horizontally  through 
two  or  more  teeth  and  their  investing  soft  tissues,  beginning 
with  the  crests  of  the  free  gingivae  and  going  rootwise  as  the 
sectioning  proceeds,  we  come  upon  this  group  of  fibers  passing 


16  SPECIAL    DENTAL   PATHOLOGY. 

from  tooth  to  tooth,  and  always  find  it  strongly  expressed.  It  is 
composed  of  many  strong  fibers,  even  after  scattering  many 
others  upward  into  the  septal  gingivae.  Often,  in  studying 
these,  it  has  seemed  to  me  that  all  of  these  fibers  could  not  be 
attached  to  the  cementum  of  the  tooth,  there  are  so  many,  and 
that  some  of  them  must  arise  within  the  tissue.  These  fibers 
have  a  work  to  do  of  physiological  importance  that  has  been 
mentioned,  and  it  will  shortly  be  discussed.  (See  Figures  8,  9 
and  10.) 

The  ALVEOLAR  CREST  GROUP.  The  fibers  of  this  group  pass 
over  to  and  are  inserted  into  the  crest  of  the  alveolar  process. 
This  group  has  sometimes  been  called  the  dental  ligament, 
though  it  has  not  the  characters  of  a  true  ligament.  These 
fibers  appear  to  best  advantage  in  longitudinal  labio-lingual  (or 
bucco-lingual)  sections.  In  studying  the  structure  in  such  sec- 
tions it  is  often  apparent  that  the  periosteum  covering  the 
alveolar  walls  extends  over  the  curve  of  the  crest  of  the  alveolar 
process  and  a  short  distance  on  the  labial  (or  buccal)  surface, 
to  give  place  for  the  attachment  of  this  group  of  fibers.  This 
group  forms  a  strong  band  of  fibers  completely  encircling  the 
tooth.  It  is,  however,  much  stronger  in  its  labial,  buccal  and 
lingual  than  in  its  proximal  portions. 

The  function  of  this  alveolar  crest  group  of  fibers  is  to  assist 
the  horizontal  group  in  sustaining  the  tooth  in  its  position  in  its 
alveolus,  especially  against  lateral  motions,  and  yet  allow  that 
slight  motion  necessary  to  the  tooth  in  performing  its  function 
in  mastication.  This  will  be  better  understood  after  studying 
the  pull  and  the  balancing  of  the  pulls  of  ditferent  groups  of 
fibers,  and  the  influences  of  disturbances  brought  about  by  inter- 
ferences with  this  balance  of  the  pull  exerted  by  the  various 
groups  of  fibers  upon  the  teeth.     (See  Figures  3,  7  and  8.) 

The  free  gingiva. 

The  free  gingivip  are  soft  tissue  processes  growing  out  from 
the  body  of  the  gingivae  and  covering  a  portion  of  the  enamel 
surface  of  the  crowns  of  the  teeth.  They  are  on  the  labial, 
buccal  and  lingual  surfaces  of  the  teeth,  and  join  the  septal 
gingivae  at  the  angles  of  the  teeth.  This  part  of  the  tissue  has  no 
attachment  to  the  teeth,  after  passing  occlusally  of  the  gingival 
line,  but  is  simply  closely  fitted  about  them;  hence  the  term 
free  gingivcB.  The  height  of  the  free  gingivae  upon  the  teeth  is 
variable,  from  one  to  five  millimeters,  sometimes  even  higher  in 
children.     In  rising  on  the  gingival  portions  of  the  crowns  of  the 


Fig.  7. 


Fig.  8. 


Figs.  7  and  8.  Diagrams  illustrating  groups  of  fibers  of  the  gingivae  and 
peridental  membrane. 

Fig.  7.  Bueco-lingual  section  through  a  bicuspid  tooth  and  investing  tissue. 
F,  Free  gingiva>  group  of  fibers,  ac,  Alveolar  crest  group  of  fibers,  ii,  Horizontal 
group  of  fil)eis.  o,  01)lique  group  of  fibers.  A,  Apical  group  of  fibers.  B,  Bone  of 
alveolar  process. 

Fig.  8.  Mesio-distal  section  througli  two  bicuspiils  and  septal  tissue.  F,  F,  Free 
gingivae  groups  of  fibers  into  septal  gingiva,  t,  Trans-septal  group  of  fibers  from 
tooth  to  tooth.  AC,  AC.  Alveolar  crest  groiips  of  fibers,  H,  il,  Horizontal  groups  of 
fibers,  o,  o,  Oblique  groups  of  fibers,  a,  a.  Apical  groups  of  fibers.  B,  bony  septum 
of  alveolar  process. 

♦a 


^te|g^§l^ii^  §Jiy  'lMS0^-^0Jk. 


"^Ss 


Fig.  9. 


i'lG.  lu. 


Fig.  9.  Cross  section  of  the  eontral  ami  lateral  incisors  a  little  to  the  incisal  of 
the  crest  of  the  alveolar  sei)tiirn.  a,  Portion  of  central  incisor,  b,  Lateral  incisor, 
c.  Pulp  elianiher  of  lateral  incisor,  d,  d.  Ceinentiiin  of  central  incisor,  e.  e,  Cementum 
of  lateral,  f,  Trans-septal  fibers  of  the  peridental  inenil)ran(>  extending  from  tooth  to 
tooth  continnonsly.  These  ar(>  attached  in  the  cenientuin  of  each  tooth,  g,  g,  Fibers 
of  the  peridental  nieiidiranc,  which  Join  with  the  coarse  fibrous  tissues,  h,  h,  of  the 
gingivae,    j,  j,  Epithelial  covering  of  the  gingiva-. 

Fig.  10.  A  portion  of  the  jieridental  nieinl)rane  between  two  incisors  of  a  young 
sheep,  showing  the  trans-septnl  fdiers  extending  from  tooth  to  tooth.     Noyes. 


^P/une      of 
oc  ciasat 

■rfaces 


Plum    of    occ/u5a/sur£aces_ 


F/am 
of  rnafqirC 
of   a/i/eoiar 

sept U  771 

Fig.   11. 


F/ane    of  marain    of  a/veo/ar    septum 
Fig.  12. 


/Marain    of  a/veo/ar  sepTum\ 
Fig.  i;'.. 


uccal 
Embrasure 


Fig.  14. 


l'i(i.  11.  Dingraiii  to  illustrate  shape  of  interproximal  space.  If  the  rectangular 
liaiiic  is  jilacfd  between  two  spheres  which  are  in  contact  at  the  point  indicated,  the 
space  within  the  frame  and  between  the  two  splieres  would  be  that  of  an  interproximal 
space  between  the  bicuspids  and  molars,  which  might  be  described  as  a  rectangular 
section  of  a  biconcave  sphere. 

Fig.  12.  Diagram  to  illustrate  the  three  divisions  of  tiie  interproximal  space. 
The  buccal  end)rasure  consists  of  that  portion  of  the  interproximal  space  to  the  buccal 
of  the  contact  point  wliieh  normally  is  not  filled  by  the  septal  gingiva.  Tlu^  lingual 
embrasure  consists  of  the  corresponding  portion  of  the  interproximal  space  to  the 
lingual  of  the  contact  point.  The  septal  space  consists  of  that  j)ortion  of  the  inter- 
proximal space  which  is  normally  filled  by  the  septal  tissue.  This  space  may  be 
ilescribed  as  a  pyramid  set  upon  a  rectangular  solid. 

Fk;.  \?>.  Diagram  to  illustrate  the  areas  on  the  proximal  surface  of  a  tooth. 
The  buccal  embrasure  area,  the  iingual  embrasure  area  and  the  septal  area  are  names 
given  to  those  poll  inns  of  the  ])roxiinal  surface  of  a  tooth  wliich  correspond  to  the 
similar  divisic.ns  of  the  interproximal  space. 

Fig.  14.  Diagram  to  illustrate  the  relation  of  the  embrasuri'S  to  the  point  of 
contact.  The  portion  of  the  interproximal  space  whicli  is  nornuilly  open  (to  the 
occlusal  of  the  septal  tissue),  is  divide<l  liy  1lie  jioiiit  of  contact  intr>  a  buccal 
embrasure  and   a    liii<iiial  eiidtrasui't\ 


Fig.  15. 


Fig.  16. 


Fig.   17. 


Fig.  18. 


Fig.  20. 


Fig.  21. 


Fig.  22. 


Fig.  23. 


Fig.  24. 


Figs.  15  to  24.  A  selection  of  teeth  to  sliow  their  jfiiijiival  lines.  Figures  15  and 
16,  upper  central  incisors.  Figure  17,  an  upper  cuspid.  Figures  18  and  19,  mesial 
and  distal  views  of  an  upper  first  bicuspid.  Figure  20.  an  upper  second  bicuspid. 
Figure  21,  an  upper  first  molar.  Figure  22,  a  lower  incisor.  Figure  23,  a  lower 
bicuspid.     Figure  24,  a  lower  first  molar. 

The  curvature  of  the  gingival  line  on  the  proximal  surfaces  of  the  incisors  and 
cuspid  may  be  compared  with  those  of  the  bicuspids  and  molars. 


THE   GINGIVA..  17 

teeth,  the  gingivae  thin  away  to  a  knife-edge  margin.  A  thin 
blade  may  readily  be  i^assed  between  the  gingiva  and  the 
enamel,  raising  the  tissue  and  exposing  the  subgingival  space 
between  it  and  the  enamel.  This  tissue  has  no  attachment  to  the 
tooth  until  the  gingival  line  on  the  tooth  is  reached,  which  means 
that  the  attachment  is  to  the  cementum  only. 

The  form  of  the  free  gingivje  to  a  labial  view  of  the  incisors 
and  cuspids  is  a  smooth,  graceful  curve  of  about  one-third  of  a 
circle  with  the  concavity  toward  the  crown  or  incisal  edge  of  the 
tooth.  This  joins  with  the  septal  gingivae  at  the  angles  of  the 
teeth,  continuing  the  curve  into  the  embrasures  well  between  the 
angles. 

The  septal  gingivje. 

The  septal  gingivae  are  processes  of  soft  tissue  growing 
up  from  each  septum  of  the  body  of  the  gingivie,  and  under 
normal  conditions  fill  each  interproximal  space  to  its  contact 
point.  At  the  angles  of  each  of  the  teeth  the  septal  tissue  joins 
smoothly  with  the  free  gingivae  by  continuity  and  even  fulness 
of  form  as  the  one  passes  imperceptibly  into  the  other.  The 
division  between  the  two  is  a  matter  of  form,  and  the  naming  of 
them  separately  is  for  convenience  in  description.  But  the 
difference  in  form  is  very  real.  Each  septal  gingiva  fills  a 
space  between  the  proximal  surfaces  of  two  teeth.  Each  labial, 
buccal  or  lingual  gingiva  clings  to  and  clothes  an  otherwise 
free  surface  of  the  enamel.  Each  septal  gingiva  has  two  sub- 
gingival spaces,  a  mesial  and  a  distal,  each  lying  against  the 
surface  of  a  tooth ;  while  each  labial,  l)uccal  or  lingual  gingiva 
has  but  one  subgingival  space.  There  is  a  difference  in  the  firm- 
ness and  plasticity  of  the  septal  gingivcT  as  compared  with  the 
labial,  buccal  or  lingual  gingivae.  This  tissue,  being  broader 
and  thicker,  has  within  it  much  more  of  plastic  tissue  and  is 
much  more  easily  compressed  than  the  free  gingivae.  After  a 
considerable  compression,  as  by  food  impaction,  it  will  again 
assume  its  normal  form,  provided  the  compression  has  not  been 
too  long  maintained.  The  dangers  which  threaten  the  two  j^arts 
of  the  tissues  are  also  different,  as  we  will  find  in  the  study  of 
their  pathology.  For  these  reasons  they  should  be  named 
separately. 

When  normal  and  of  good  form,  the  septal  gingivjr  are 
more  or  less  wedge-shaped  and  fill  the  greater  portion  of  the 
space  between  the  teeth  from  the  gingival  line  to  the  contact 
point,  the  occlusal  edge  or  surface  sloi)ing  away  from  the  contact 


18  SPECIAL   DENTAL   PATHOLOGY. 

point  buccally  and  lingiially  toward  the  gingival  to  the  l6vel  of 
the  buccal  and  lingual  free  gingivic.  The  open  spaces  on  either 
side  of  the  contact  point,  to  the  occlusal  of  the  septal  tissue,  are 
called  the  buccal  and  lingual  embrasures.  It  is  through  these 
that  food,  cruslied  between  the  teeth  and  divided  by  the  contact 
points,  glides  upon  the  sloping  surfaces  of  the  septal  gingivae  to 
either  side  of  the  arch.  This  sliding  is  facilitated  by  the  widen- 
ing of  the  embrasures  to  the  buccal  and  lingual,  by  the  slope  of 
the  surfaces  of  the  septal  gingivae  and  by  the  lubrication  by 
mucus. 

It  should  be  particularly  noted  that  this  description  pro- 
vides a  deeper  filled  jjortion  and  a  superficial  open  portion  of  the 
general  interproximal  space;  the  deeper  portion,  occupied  by 
the  septal  tissue,  may  be  termed  the  septal  space,  while  the 
superficial  portion  consists  of  the  buccal  (or  labial)  and  lingual 
embrasures.     (See  Figures  11,  12, 13  and  14.) 

The  form  of  the  surface  of  the  septal  gingiva  which  is 
exposed  to  the  food  which  glides  over  it,  is  very  similar  to  that 
of  an  inverted  letter  V,  with  the  angle  of  meeting  of  the  two  legs 
of  the  letter  at  the  contact  point,  and  the  legs  extending  buccally 
and  lingually.  The  angle  formed  by  the  two  lines  may  be  a 
right  angle  in  the  incisor  and  bicuspid  regions,  or  even  less  when 
the  teeth  have  long  bell-shaped  crowns.  Between  thick-necked 
teeth,  especially  between  the  molars,  it  may  be  an  obtuse  angle, 
the  slopes  to  either  side  being  comparatively  flat,  yet  there  is 
sufficient  slope  to  the  buccal  and  lingual,  aided  by  the  broadening 
of  the  open  embrasures  and  by  the  lubrication  by  mucus,  for 
food  separated  by  the  contact  to  glide  to  the  sides  of  the  arch 
without  difficulty.  The  best  form  of  the  gingivae  does  not  permit 
any  unevenness  in  the  fulness.  Any  depression  —  one  that 
lowers  a  free  margin  and  thickens  it  especially,  is  a  fault  which 
endangers  the  integrity  of  the  tissues  by  facilitating  lodgments 
on  the  teeth. 

At  the  point  of  contact,  between  any  two  teeth,  the  septal 
tissue  is  reduced  to  a  very  thin  edge;  this  becomes  thicker  pro- 
gressively as  we  pass  toward  the  gingival  line,  to  fill  the  space 
made  by  the  greater  separation  of  the  surfaces  of  the  teeth,  so 
that  in  some  of  these  spaces  the  tissue  becomes  a  comparatively 
thick  mass.  In  the  buccal  and  lingual  directions,  the  thickness 
of  the  tissue  increases  as  the  teeth  round  away  from  each  other 
in  forming  the  embrasures  toward  their  buccal  and  lingual 
surfaces,  until  it  meets  evenly  with  the  free  gingivae  at  the  angles 
of  the  teeth.     In  this  slope,  between  the  teeth,  the  surface  of  the 


THE   GINGIVA.  19 

septal  tissue  is  flat  mesio-distally,  and  joins  against  the  teeth  in 
a  right  angle  as  it  is  reflected  to  form  the  surfaces  of  the  sub- 
gingival spaces  to  the  mesial  and  distal  sides  of  its  substance. 

EPITHELIUM    OF   THE   GINGIVA. 

The  epithelial  covering  of  the  gingivsB  is  one  of  the  very 
important  elements  of  their  histological  structure.  Immedi- 
ately after  passing  the  position  of  the  line  of  the  crest  of  the 
bony  alveolar  process  in  going  toward  the  crests  of  the  free 
gingivae,  we  find  the  epithelial  covering  becoming  thicker  and 
stronger,  with  the  cellular  elements  themselves  smaller  and  more 
closely  interwoven.  As  the  epithelium  becomes  thicker,  the 
interdigitation  of  the  connective  tissues  beneath,  into  the  epithe- 
lial covering,  becomes  longer,  more  closely  set  and  finer.  In 
proportion  as  the  epithelial  covering  becomes  thicker,  do  we  find 
the  connective  tissue  elements  becoming  smaller,  more  thickly 
set  and  finer,  until  they  are  reduced  to  fine  strings  of  connective 
tissue  elements,  each  carrying  a  minute  arteriole  and  returning 
vein  with  a  rich  little  capillary  circulation  about  them,  thus 
carrying  an  arterial  circulation  almost  completely  through  this 
thick  mass  of  epithelimn  for  its  growth  and  support. 

If  the  superficial  epithelial  cells  in  the  live  tissue  in  the 
gingivae  are  scraped  away  with  a  sharp  instrument,  blood  will 
ooze  out  long  before  any  considerable  portion  of  the  epithelium 
has  been  removed.  The  bleeding  is  the  result  of  cutting  the 
ends  of  the  long  connective  tissue  prolongations  into  the  body  of 
the  epithelium,  which  carry  the  blood  for  the  support  and  quick 
growth  of  epithelial  cells  for  the  repair  of  abrasions  and  cuts 
received  in  chewing  coarse  foods.  If  a  careful  examination  of 
this  scraped  spot  is  made  on  the  morrow,  no  trace  of  the  injury 
will  be  found.  Each  of  these  minute  ends  of  connective  tissue, 
carrying  these  delicate  blood  vessels,  has  a  complete  clothing  of 
young  epithelial  cells  around  it,  ready  to  spring  out  and  supply 
new  cells  for  any  such  break  which  may  occur.  These  loops  are 
so  closely  placed  that  but  few  new  cells  are  retjuired  from  each. 

The  surface  of  this  tissue  is  arranged  for  the  repair  of  any 
such  scrapings  of  its  surface  which  may  occur  in  the  chewing  of 
food.  This  epithelium  is  continued,  and  these  ends  of  connec- 
tive tissue  carry  the  blood  supply  to  the  tliinnest  part  of  the 
finest,  apparently  knife-edge  of  the  crest  of  the  free  gingivae  of 
the  labial,  buccal  and  lingual  surfaces  of  the  teeth.  Then  the 
epithelium  is  doubled  or  reflected  over  the  thin  margin,  and  it 
clothes  also  the  portion  of  the  soft  tissue  forming  the  subgingival 


20  SPECIAL   DENTAL   PATHOLOGY. 

space,  down  to  the  attachment  of  the  peridental  membrane  at 
the  gingival  line.  Within  the  subgingival  space  the  layer  of 
cells  is  much  tliinner,  and  especially  are  they  much  softer  and 
seom  to  permit,  possibly  facilitate,  the  escape  of  a  fluid  which 
continually  bathes  the  subgingival  space. 

In  the  last  analysis  it  is  seen  that  the  epithelium,  taken  as  a 
whole,  makes  up  quite  a  large  bulk  of  the  tissue  in  that  part  of 
the  gingivjB  closely  surrounding  the  teeth  on  their  labial,  buccal 
and  lingual  surfaces. 

Epithelium  of  the  septal  gingiv-e. 

That  portion  of  the  surface  of  the  septal  gingivae  which  is 
exposed  to  the  friction  of  food  forced  over  it  in  the  process  of 
mastication  is  covered  with  epithelium  which  in  all  respects  is 
similar  in  quality  and  thickness  to  that  described  as  belonging 
to  the  free  gingivae  of  the  labial,  buccal  and  lingual  surfaces. 
The  epithelium  is  reflected  over  its  margin  onto  the  tissue  lining 
of  the  subgingival  spaces,  mesial  and  distal,  in  the  same  manner 
and  with  a  similar  thin  coating  of  a  softer  quality  of  epithelium. 

In  microscopic  sections  which  are  cut  through  the'  septal 
gingivae  parallel  with  the  long  axis  of  the  tooth  mesio-distally, 
we  find  a  mass  of  epithelium  that  has  much  the  appearance  of  a 
lobulated  gland,  buried  centrally  in  the  bucco-lingual  direction, 
at  a  somewhat  variable  depth.  This  may  be  termed  the  septal 
gland.  This  lobulated  mass  varies  much  in  size  in  different 
septal  gingivae.  Between  teeth  that  lie  very  closely  together  at 
their  gingival  lines,,  giving  little  room  for  the  septal  gingivae,  the 
amount  of  the  mass  is  so  small  that  it  might  easily  escape 
observation.  Wlien  the  space  between  the  teeth  is  wide  at  the 
gingival  line,  this  lobulated  mass  is  sometimes  a  prominent 
object.  Frequently  it  extends  some  distance  into  the  septum  of 
the  body  of  the  gingivae. 

If  this  mass  of  lobulated  epithelium  is  a  gland  at  all,  it  is  a 
ductless  gland  of  very  small  dimensions.  It  is  easily  seen  and 
its  tissue  can  be  well  studied;  if  ducts  were  there,  they  could 
easily  be  found.  I  can  not  now  think  of  this  bit  of  lobulated 
epithelium  as  of  any  special  importance.  But  the  regularity  of 
its  appearance  in  this  position,  and  the  fact  also  that,  in  com- 
paratively recent  time,  certain  ductless  glands  of  small  size  have 
been  demonstrated  to  have  functions  of  great  importance,  should 
cause  us  to  be  careful  about  casting  this  matter  aside  as  unim- 
portant. Some  one  may  yet  find  it  to  be  of  physiological  impor- 
tance in  the  performance  of  some  as  yet  unknown  function. 


Fig.  25, 


Fig  25  Longitiulinal  section  of  a  deciduous  incisor  tooth  of  kitten  with  its 
membrane  and  alveohis.  The  actual  length  of  the  tooth  hero  ''^^7^''"^'^''  ,:;■;;,,;;";;" 
fourth  of  an  inch,  a,  Crown,  b,  Pulp  chamber  and  root  cana  .  c  *;»""■ 
d  d  d  d,  Alveolar  walls,  e,  Apical  space  and  apical  foramen,  t,  t,  t  t  l.u  untai 
m'em'brane.  g,  g,  The  gingival  portion  of  the  peridental  me.nbrane  '^'^}'^ 
n  n,  The  periosteum  of  the  outer  surface  ot  alveolar  wa  1.  h.  h,  1  m  g>i^,'^.i- 
i  i  Epithelium,  k,  k,  Coarse  fibrous  tissne  of  the  gums.  1.  i.  1.  Hloo.l  vessels  t.a- 
versing  the  peridental  membrane,  m,  Saciib.s  of  p.T.nauenr  tooth,  o,  Periosteum 
p,  Attachment  of  labial  muscles.  Th-  intention  of  xW  illnslrafon  .s  to  give  a  full 
liew  of  the  peridental  membran.-.  an,!  tl,.  nlatiun^  m  llir  tooth.  ,n-,nhran,.  and 
alveolar  wall. 


Fig.  26. 


Fig.  26.  Cross  section  of  cuspid  tooth  with  peridental  membrane  and  alveolar 
wall  cut  through  the  thickened  rim  at  the  gingival  portion  of  the  alveolar  wall,  from 
a  man  forty  years  old.  The  membrane  was  very  thin  and  firm,  and  a  large  piece  of 
the  labial  wail  of  the  alveolus  adhered  to  the  tooth  when  extracted.  It  represents  an 
extremely  thin  peridental  membrane,  while  Figure  98  represents  one  that  may  be 
regarded'  as  thick,  a,  a,  Peridental  membrane,  b,  b,  Cementum.  c.  e,  Alveolar  pro- 
cess, d,  d.  Dentin.  It  will  be  observed  that  most  of  the  blood  vessels  of  the  peri- 
dental membrane  lie  in  depressions  in  the  alveolar  wall. 


THE    GINGIViE.  21 

The  hokmone.  In  the  human  body  and  in  the  bodies  of 
animals  there  are  a  considerable  number  of  ductless  glands, 
large  and  small,  some  of  which  have  been  carefully  studied,  and 
others  have  not.  Of  these  the  spleen  is  much  the  largest.  Its 
functions  have  not  been  completely  made  out,  but  it  seems  to 
have  a  relation  to  blood  formation. 

The  other  ductless  glands  in  their  normal  state  are  very 
much  smaller.  Perhaps  the  most  important  of  these,  both  in  the 
physiological  sense  and  in  pathological  relations,  are  the  thyroid 
gland  and  the  suprarenal  glands.  The  former  is  located  about 
the  trachea,  and  the  latter  in  the  suprarenal  capsule  of  the 
kidney.  The  thyroid  gland  is  subject  to  many  changes  and 
diseases,  the  most  important  of  which  is  exopthalmic  goitre,  due 
to  the  production  of  a  greatly  increased  amount  of  secretion, 
which  acts  as  a  systemic  poison.  The  removal  of  this  gland 
results  in  a  disease  called  myxedema  in  adults,  or  cretinism  in 
children,  which  may  terminate  fatally.  The  central  and  one 
lateral  lobe  are  usually  removed,  also  part  of  the  remaining 
lateral  lobe  may  be  removed,  with  great  benefit  to  patients 
suffering  from  exopthalmic  goitre.  To  destroy  the  suprarenal 
glands,  and  they  are  liable  to  be  destroyed  by  tuberculosis,  is  to 
bring  on  disease  of  a  wasting  character,  which  ends  in  death. 
To  remove  these  bits  of  tissue  by  operation,  has  a  like  effect. 

The  brain,  the  thj^roid  gland,  the  suprarenal  gland,  the  liver 
and  muscles  form  a  group  of  organs  whose  function  is  to  convert 
potential  into  kinetic  energy.  That  is  to  say,  latent  energy  is 
converted  into  motion  and  heat  in  response  to  adequate  stimuli, 
but  if  these  stimuli  are  too  intense,  as  a  result  of  severe 
muscular  exertion,  strong  emotion,  traumatism,  toxins,  etc., 
the  cells,  especially  those  of  the  cerebellum  (more  specifically, 
the  Purkinje  cells)  become  exhausted  and  may  be  permanently 
disintegrated.  Crile's  theory  of  preventing  shock  consists  in 
weakening  or  breaking  the  kinetic  chain  at  any  point.  There 
are  two  ways  of  breaking  this  chain.  One  is  by  anesthetics 
which  prevent  the  brain  from  receiving  psychic  shock  and  the 
other  b}^  blocking  the  nerve  tracts  to  prevent  the  brain  from 
receiving  tlie  shock  of  traumatism.  Both  must  be  employed  to 
carry  out  Crile's  plan. 

In  the  study  of  these  ductless  glands,  it  has  been  found  that 
each  produces  a  chemic  body,  or  several  of  them,  known  as 
hormone,  pi.  hormones  (Greek),  meaning  to  excite,  to  arouse. 
This  chemic  substance  is  different  for  each  ducth'ss  gland;  that 
is,  each  ductless  gland  secretes  or  elaboiatcs  its  own  liorinone. 


22  SPECIAL    DENTAL   PATHOLOGY. 

These  are  formed,  we  may  suppose,  much  as  other  secretions, 
but  instead  of  being  conveyed  to  their  destination  in  ducts,  they 
are  delivered  immediately  into  the  blood  stream  passing  through 
them,  and  in  this  way  are  carried  to  the  organ  with  which  they 
are  associated,  and  which  they  arouse  to  action.  The  organ 
excited  in  this  way  may  be  at  a  distance  from  the  gland  forming 
the  hormone.  It  seems  very  curious  that  just  a  little  bit  of  duct- 
less lobulated  glandular  tissue,  like  the  suprarenal  glands, 
should  have  so  important  a  physiologic  function.  The  drug 
adrenalin  is  derived  from  the  suprarenal  glands  of  animals. 
We  do  not  know  but  that  some  one  may  yet  discover  that  these 
ductless  glands  distributed  in  the  septal  gingivjE,  may  also  have 
some  important  function. 

DEVELOPMENT    OF    THE   GINGIVA. 

Well-known  facts  warrant  the  statement  that  after  the  intra- 
uterine period,  or  after  the  animal  of  whatever  kind  has  entered 
upon  an  independent  existence,  new  tissues  needed  in  growth  are 
not  developed  until  other  conditions  have  rendered  their  func- 
tion necessary.  Certainly  a  bony  alveolar  process,  creating  an 
alveolus,  is  not  developed  until  there  is  a  tooth  around  which  to 
build  it.  In  the  same  way,  a  gingiva  does  not  grow  until  there 
is  a  tooth  about  which  it  may  entwine  its  tissue. 

When  a  child  is  born  a  primary  alveolar  ridge  is  found, 
which  is  serving  as  a  housing  for  the  developing  teeth.  When 
a  new  tooth  makes  its  way  to  tjie  surface,  this  primary  alveolar 
ridge  about  it  is  being  absorbed  to  give  it  exit,  and  an  alveolar 
process  of  bone  is  forming  around  it.  The  soft  tissue  covering 
of  this  is  simple  gum  tissue.  There  is  no  appearance  as  yet  of 
the  body  or  processes  of  the  gingivse.  As  the  crown  of  the  tooth 
is  pushed  forward,  a  considerable  part  of  this  gum  tissue  is 
absorbed  from  over  it,  but  a  remaining  part  is  pushed  aside. 
Just  at  the  time  of  the  release  of  the  coming  tooth  from  restraint, 
by  the  absorption  of  the  bone  covering  it,  the  tooth  comes 
forward  quickly,  so  that  within  a  very  few  days  it  is  finding  its 
occlusion  with  its  fellow  of  the  opposing  maxilla.  In  this  last 
rapid  movement  any  part  of  gum  tissue  in  the  way  is  simply 
pushed  aside.  This  often  gives  the  soft  tissue  about  the  new 
tooth  a  ragged  appearance  for  a  few  days.  These  tissues  seem 
to  be  overfull  and  swollen ;  the  embrasures  may  be  overfull  with 
the  soft  tissue  standing  out  of  them  in  festoons.  The  child  may 
complain  of  some  transient  pain  from  biting  food  upon  this,  but 


THE    GINGIVA.  23 

within  a  few  days  it  is  trimmed  down  to  better  dimensions  by 
absorption. 

The  proper  forms  and  structure  of  the  gingivas  have  not  yet 
grown.  There  is  not  only  absorption,  which  reduces  the  surface 
form  of  the  tissue,  but  also  absorptions  everywhere  tvithin  the 
tissue  and  growth  of  those  tissue  forms  belonging  to  the  gingivae 
proper.  This  is  rapidly  built,  the  new  displacing  the  old,  and 
within  a  month  or  two  the  gingival  tissue  will  have  been  com- 
pleted and  ready  to  perform  its  usual  functions.  The  teeth  are 
apt  to  present  in  pairs,  of  like  kind  one  on  either  side  of  the 
mouth,  or  four,  including  the  teeth  of  both  upper  and  lower 
jaws,  and  as  these  erupt  the  growth  of  the  proper  membranes 
and  gingivas  for  pair  after  pair,  lower  and  upper,  is  proceeding. 
The  changes  which  take  place  in  these  tissues  during  this  period 
are  very  rapid.  The  children,  however,  if  healthy,  go  on 
through  it  all  with  only  a  twinge  of  pain  now  and  then,  when 
they  forget  and  bite  food  against  some  bit  of  ragged  tissue 
freshly  pushed  aside.  It  is  repetition  after  repetition  of  this 
process,  with  but  little  variation,  from  the  time  of  the  eruption 
of  the  first  of  the  deciduous  teeth  until  the  last  of  the  permanent 
teeth. 

During  these  growths  of  the  outward  forms,  the  tissues  are 
making  interstitial  growth.  The  fibers  of  the  gingival  portion 
of  the  now  scant  cementum  are  growing  and  forming  their 
groups.  These  groups  include  the  alveolar  crest  group,  running 
out  to  the  crest  of  the  alveolar  process  or  to  the  condensed  tissue 
of  the  surface  of  its  periosteum,  also  scattering  fibers  which 
extend  into  the  body  of  the  gingivae.  The  group  of  fibers,  turn- 
ing occlusally  to  form  the  free  gingivae  group,  take  their  places. 
The  fibers  of  the  trans-septal  group,  which  tie  the  teeth  solidly 
together  mesio-distally,  grow  out  through  the  septal  tissues  and 
form  their  junctions  with  each  other,  making  these  important 
groups  solid  and  strong.  The  gum  tissue,  with  its  coarse 
fibrous  mat,  is  changed  for  a  finer  network  united  with  the  fibers 
from  the  peridental  membrane.  The  length  of  the  body  of  the 
gingivae  increases  as  the  teeth  move  farther  out  from  their  liony 
alveoli,  and  form  longer  soft  tissue  alveoli. 

Finally,  while  all  of  this  is  in  progress,  the  epithelial  cover- 
ing is  being  reformed.  Indeed  this  tissue  is  being  actively 
regenerated  during  life,  but  during  this  time  it  is  rapidly  chang- 
ing its  qualities  and  forms,  the  cells  becoming  smaller  and  more 
closely  interwoven.  The  mass  of  cellular  elements  become  more 
and  more  thickened.     The  interdigitation  of  fine,  closely  set  con- 


24  SPECIAL   DENTAL   PATHOLOGY. 

nective  tissue  fingers  into  this  epithelium  is  grown  and  brought 
into  complete  form  throughout  every  part  of  the  tissue. 

During  this  time  the  outward  form  is  not  neglected.  As 
growth  proceeds,  more  and  more  of  the  crown  of  the  tooth  pro- 
trudes through  the  gingivae  and  the  depth  of  the  subgingival 
space  is  diminished.  The  changes  are  grown  in  the  gingival 
tissue  to  accomplish  this,  and  go  on  continuously  to  the  adult 
period.  The  tissue  is  trimmed  down  here  and  its  fulness 
increased  there  until  an  even  smoothness  of  foim  is  produced  in 
the  whole  compound  of  soft  and  hard  tissues  which  gives  a 
smooth  exterior  with  an  intimate  network  of  soft  tissues  wound 
about  the  teeth.  This  fills  perfectly  every  interstice  between 
and  about  them  in  such  a  way  as  to  prevent  lodgments  of  debris 
or  food  occurring  at  any  point. 

Such  is  the  picture  of  a  perfect  development.  Unfortu- 
nately, we  do  not  always  find  it  so  perfect,  nor  do  we  always 
employ  the  best  means  to  correct  and  smooth  over  and  improve 
the  imperfect  points,  or  protect  those  which  are  good,  from 
abuse. 

The  fibers  from  the  peridental  membrane  distributed  in 
these  tissues  serve  to  bind  the  whole  group  into  a  solid  mass,  or 
into  a  mass  that  has  a  very  powerful  controlling  effect  upon  the 
establishment  of  the  dental  arch  along  right  lines,  and  maintain- 
ing it  in  this  form.  The  development  of  any  inflammation  in 
this  tissue  serves  to  soften  the  fibers  and  causes  them  to  stretch 
more  easily,  or  even  causes  them  to  swell  and  occupy  too  much 
space.  This  often  throws  this  tissue  out  of  form,  interfering 
with  its  close  adaptation  to  the  teeth,  and  roughening  the  mar- 
gins of  the  free  gingiva?,  causing  them  to  receive  lodgments 
instead  of  shedding  such  material  away  during  the  process  of 
mastication,  as  they  should  do.  This  will  be  studied  more  in 
detail  later  on. 

The  SUBGINGIVAL  SPACES.  The  subgingival  spaces  have  been 
sufficiently  defined.  Any  particular  subgingival  space  will  be 
located  bj^  naming  the  tooth  to  which  it  belongs,  as,  the  lower 
left  c_entral  incisor  subgingival  space.  The  parts  may  be  desig- 
nated by  naming  the  surfaces  of  the  tooth  which  are  covered,  as 
the  mesial,  distal,  lingual,  labial  or  buccal  subgingival  spaces, 
for  each  tooth.  If  it  should  become  necessary,  and  it  will,  we 
can  particularize  almost  any  part  of  the  subgingival  space,  as 
the  subgingival  space  at  the  disto-buccal  angle  of  the  upper  first 
bicuspid,  etc.  Wliile  we  name  these  various  parts,  it  should  be 
particularly  noted  that  the  subgingival  space  really  encircles  the 


*^v:„--* 


:'^i7!^vr}^^/ 


Fig.  21 


<i^^ 


Fig.  29. 


-  --'-■^v?!^f55'- 


Fig.  30. 


Fig.  31. 


Figs.  27  to  42.     A  series  illustrating  the  growth  of  connective  tissue. 

Fig.  27.  Embryonal  connective  tissue  in  an  early  stage  of  development,  showing 
the  cellular  elements  imbedded  in  the  ground  substance. 

Fig.  2.S.  The  same,  a  little  more  developed,  showing  Mie  .•elluhir  elements  length- 
ening in  a  common  direction. 

Fig.  29.  The  cells,  .ievelcp.-d  in  simidh'  forms,  lihn.l. lasts  with  h.ng  lilaments 
extending  from  either  end. 

Fig.  30.     The  developed  white  ld)rous  tissue. 

Fig.  31.  Older  white  fibrous  tissue,  in  which  thr  cells  arc  no  longer  seen,  and 
showing  the  wave  like  course  of  the  fibers. 


Fig.  32. 


Fig.  33. 


Fig.  34. 


■.'^: 


Fig.  35. 


Figs.  27  to  42.     A  series  illustrating  the  growth  of  connective  tissue. 

Fig  32  Coarse  white  fibers,  made  up  of  bundles  of  the  fine  fibers,  and  showing 
the  mode  of  division  by  the  splitting  off  of  a  portion  of  the  fibers  of  the  bundle. 

Fig.  33.     Coarse  fiber  breaking  up  into  fine  fibers. 

Fig.  34.    Cross  sections  of  coarse  fibers  showing  some  of  their  various  forms. 

Fig.  35.  Tissue  of  the  dental  pulp,  in  which  the  development  of  the  cells  is  not 
followed  bf  any  considerable  formation  of  fibers. 


Fig.  36. 


Fig.  37. 


Fig.  38. 


Figs.  27  to  42.     A  series  illustrating  the  growth  of  connective  tissue. 
Fig    36      Connective  tissue  cells  from  which  reticular  fibers  arc  developed. 
Fig.  37.     Eeticulav  fibers,  showing  the  mode  of  division  and  the  multipolar,  or 
irregular  star  forms  of  the  cells  at  the  divisions. 

Fig.  38.     Cross  sections  of  the  reticular  fibers,  showing  some  of  tlirir  torms. 


Fig.  39. 


Fig.  jo. 


Fig.  41. 


Fig.  42. 


Figs.   27  to  42.     .\   scries  illustraling  the  growth   of  connective  tissue. 
Fig.  39.     Network  of  elastic  fibers  teased  out  from  elastic  tendon,  and  showing 
the  usual  mode  of  division. 

Fig.  40.     Network  of  elastic  fibers  from   tlie  point   of  reflection   of  the  mucous 
membrane  of  the  lip  from  the  gums. 

Fig.  41.     Elastic  fibers,  showing  tlieir  disposition  to  curl  up  when  cut  or  broken. 
Fig.  42.     Cross  sections  of  '_^las1ic  fibers,  showing  their  forms  as  seen  in  a  group 
passing  between  coarse  white  fibers. 


Fig.  43. 


Fig.  4H.  a  photomicrograph  from  a  cross  section  of  hone  from  the  human  femur 
from  a  young  person,  a,  Tiiis  line  crosses  laminic  of  subperiosteal  hone.  B,  These 
lines  point  out  IIa\ersian  system  bone.  These  Haversian  systems,  that  are  seen  to 
form  the  bulk  of  tissue,  are  formed  by  the  absorption  of  the  original  subperiosteal 
bone  and  buililing  iu  tlie  Haversian  svs'tem  bone. 


■•:^.:«:; 


~ '_^3s     J*;;  ^  i*,> 


JSTaI 


"y*^^***!*^ 


i^^f**mK^- 


^^>^^4^-s*^".'>.»»-^ 


Fig.  44. 


Fig.  14.  Lengthwise  section  from  the  same  bone,  as  illustrated  in  Figure  43, 
showing  the  Haversian  systems  and  their  canals  cut  lengthwise.  A,  Subperiosteal  bone. 
B,  A  Haversian  canal. 


Fig.  45. 


Fig.   45.      A   photomierograpli    of   bono    in    process    of   absorption,      a.    Line   of 
absorption  showing  the  lacunie  of  Howship. 


Fig.  AC). 


Fjg.  46.     Osteoclast  absorption  of  bone  over  permanent  tooth:     oc,  Osteoclasts. 
B,  Bone  of  crypt  wall,     p,  Fibrous  tissue  of  follicle  wall,     a,  Ameloblasts.     Noyes. 


THE   GINGIVA.  25 

entire  circumference  of  the  tooth  without  break.  We  divide  it 
into  parts  by  these  names,  for  convenience  in  description.  The 
labial  or  buccal  subgingival  space  means  simply  that  part  of  the 
general  subgingival  space  completely  surrounding  the  tooth, 
which  covers  the  labial  or  buccal  surface. 

It  will  be  noted  from  the  above  that  I  have  made  use  of  the 
same  terms  in  naming  the  parts  of  the  gingiva?  and  subgingival 
space  as  have  been  previously  used  in  the  descriptions  of  the 
surfaces  of  the  teeth. 

Exploration  of  the  subgingival  spaces.  Some  of  the  worst 
forms  of  disease  of  the  peridental  membranes  begin  in  the 
depths  of  the  subgingival  spaces  about  the  attachment  of  the 
tissue  to  the  teeth.  Therefore,  the  exploration  of  these  spaces  is 
of  first  importance  as  a  preparation  for  the  early  detection  of 
diseases  of  this  character.  This  exploration  may  be  made  with 
any  ordinary  thin,  flat  scaling  instrument,  the  sharp  angles  and 
working  edge  of  which  have  been  rounded  off.  Instruments 
made  especially  for  this  purpose  are  to  be  preferred.  These 
will  be  described,  and  detailed  instructions  for  their  use  given, 
under  the  consideration  of  examinations  of  the  mouth. 

In  the  examination  of  a  number  of  persons,  ranging  from 
eight  to  forty  years,  one  will  gain  a  correct  idea  of  the  changes 
which  occur  in  the  depth  of  the  gingivae  as  age  advances,  which 
will  be  very  useful,  and  can  not  be  so  well  learned  in  any  other 
way.  Experience  in  subgingival  examinations  will  enable  one  to 
detect  the  beginnings  of  disease  at  the  attachment  of  the  peri- 
dental meml)rane.  For  this  purpose,  such  a  course  of  experi- 
mental study  is  actually  essential.  One  should  examine  hun- 
dreds of  cases  of  normal  gingiva?  before  he  is  ready  to  study 
diseased  conditions  of  this  tissue. 

In  making  such  a  series  of  examinations,  one  will  obtain 
much  other  valuable  information  regarding  the  subgingival 
spaces.  It  will  be  found  that  the  distance  from  the  incisal  edge 
of  the  central  incisor  to  the  gingival  line  is  much  greater  upon 
the  labial  surface  than  on  the  proximal  surface,  yet  the  gingivic 
will  be  longest  on  the  proximal  surface.  This  is  because  of  the 
form  or  direction  of  the  gingival  line  around  the  incisor  tooth. 
This  line  is  curved  upon  the  labial  surface  with  the  concavity 
toward  the  incisal  edge  of  the  tooth.  It  passes  around  the  proxi- 
mal surfaces  in  a  curved  line  which  presents  its  convexity  toward 
the  incisal  edge  of  the  tooth.  This  foi-m  of  the  line  of  attach- 
ment, the  gingival  line,  is  common  to  the  incisor  teeth  and  the 
mesial  surfaces  of  the  cuspids,  above  and  below.     The  distal 


26  SPECIAL    DENTAL    PATHOLOGY. 

surface  of  the  cuspid  usually  lias  only  a  slight  curve  toward  the 
incisal.  On  the  bicuspids  and  molars  the  usual  course  of  the 
gingival  line  is  more  nearly  directly  around  the  tooth.  (See 
Figures  15  to  24.) 

On  some  teeth  the  gingival  line  has  irregularities  which 
one  should  be  able  to  recognize.  These  irregularities  consist  in 
what  I  have  called  bridges  and  pitfalls.  As  the  instrument  is 
passed  around  the  tooth  feeling  the  attachment,  it  may  strike  a 
bridge,  a  point  where  the  attaclmient  is  higher  on  the  crown. 
At  this  point  there  is  a  spot  of  thickened  cementum  that  has 
lapped  a  little  more  than  usual  upon  the  enamel.  On  carefully 
lifting  the  end  of  the  instrument  onto  this,  it  is  often  found  to 
be  of  only  slight  extent  and  then  again  drops  to  the  general  level. 
On  the  other  hand,  the  instrument  may  drop  into  a  depression 
in  the  line  around  the  tooth.  These  also  may  be  very  narrow, 
after  which  the  line  resumes  the  general  level.  It  is  essential 
that  one  should  become  well  acquainted  with  these,  so  that  he 
may  not  mistake  them  for  beginning  pus  pockets. 

FUNCTIONS   OF   THE   GINGIVA. 

A  PEOTECTivE  TISSUE.  The  function  of  the  gingivtB  of  first 
importance  is  that  of  a  protective  tissue.  This  is  a  passive 
function  exerted  through  the  form  and  solidity  of  its  structure, 
as  it  is  fitted  and  wound  about  every  part  of  the  teeth,  filling 
smoothly  all  interstices  and  shielding  the  tissues  beneath.  When 
this  form  is  good  the  membranes  of  the  teeth  will  be  well  pro- 
tected from  injury.  When  this  form  is  not  good,  these  will  be 
more  liable  to  injury. 

The  hard  tissues  of  the  teeth  become  useless  without  their 
soft  tissue  investment.  Their  usefulness  depends  directly  upon 
the  strength  and  healthfulness  of  that  investment.  It  is  not 
enough  that  the  gingivae  by  the  aid  of  the  bony  alveolar  process 
hold  the  teeth  strongly  in  their  positions.  The  forms  which  they 
entwine  about  the  teeth  must  be  such  as  will  shed  off  the  debris 
of  mastication  and  prevent  all  lodgments  about  them,  which  in 
their  decomposition  would  give  rise  to  offensive  and  disease- 
producing  compounds.  To  do  this,  every  part  of  the  surface  of 
the  gingivae  must  be  of  such  form  as  to  fill  all  interstices  full 
enough,  but  not  too  full,  and  thus  be  effective  for  both  cleanli- 
ness and  accommodation  of  food  movements  in  the  acts  of  masti- 
cation and  deglutition. 

The  outward  form  of  the  gingivae  in  and  of  itself,  is  of  the 
utmost  importance.     The  maintenance  of  this  is  one  of  the  first 


THE   GINGIViE.  27 

elements  of  good  service  in  dentistry.  Any  deviation  from  the 
best  form  constitutes  a  barrier  to  the  health  of  the  teeth  and 
their  investment  —  the  gingivsB  and  the  peridental  membranes. 
In  the  past,  dentists  have  treated  the  gingivas  as  unimportant, 
and  have  not  studied  them.  Often  they  have  wantonly  destroyed 
them,  especially  the  septal  gingivae,  in  connection  with  the  filling 
of  proximal  cavities.  Now  we  are  finding  the  reward  in  an 
increase  of  disease  beginning  at  the  gingival  line. 

For  a  number  of  years  I  have,  whenever  opportunity 
offered,  studied  conditions  controlling  deposits  upon  artificial 
dentures.  I  have  worn  a  plate  myself,  and  often  have  had 
several,  upon  which  I  could  study  places  of  deposit  at  will. 
In  every  case  a  depression  has  meant  a  place  of  deposit  of  some  I 
kind.  In  some  of  these  food  lodges,  remains  and  is  decomposed ; ' 
in  others  perhaps  calculus  gathers;  in  others  there  may  be  a 
cheesy  deposit,  or  some  form  of  debris.  Deposits  upon  artificial 
dentures  are  in  different  positions  from  deposits  in  the  normal 
mouth.  The  whole  surface  of  the  plate  may  become  susceptible 
of  receiving  and  holding  deposits. 

In  the  mouth  that  is  normal  there  is  but  one  deposit  on  the 
soft  tissues,  and  that  is  mucus  which  renders  the  surface  of  the 
epithelium  slippery,  so  that  material  of  almost  any  kind  glides 
easily.  This  is  normal  and  is  present  in  every  mouth.  It  is, 
however,  sometimes  in  abnormally  large  quantity,  and  some- 
times in  scant  quantity.  This  seems  to  have  little  in  common 
with  other  deposits.  A  short  gingiva  which  causes  a  depres- 
sion about  a  tooth  generally  makes  a  place  for  the  lodgment  of 
calculus  or  cheesiform  deposits.  True,  it  makes  some  difference 
where  it  is  located.  If  on  the  buccal  surfaces  of  the  molars,  it 
is  certain  to  catch  calculus  if  any  at  all  comes  into  the  mouth. 
If  there  is  much  calculus  coming  into  the  mouth,  it  will  catch 
some  of  it,  no  matter  where  it  is  located.  The  same  is  true  to 
even  a  greater  extent  with  the  cheesiform  deposits,  which  will 
be  studied  later. 

One  should  understand  distinctly  that  these  deposits,  other 
than  mucus,  may  occur  anj^iere,  where  there  are  hard  tissues 
or  mechanical  appliances  on  which  they  can  lodge.  In  the 
mouth  the  deposit  can  not  occur  except  on  the  teeth  or  some  hard 
substance  placed  in  the  mouth.  It  never  adlieres  to  the  mucous 
membranes  or  other  soft  tissues.  If  present,  as  sometimes 
occurs,  in  soft  tissue  cavities,  as  in  the  tonsils  or  nose,  the  initial 
deposit  is  on  some  hard  or  dead  substance  which  furnishes  a 
nidus.     A  beginning  is  never  madeon  living  soft  tissue.     This 


28  SPECIAL    DENTAL    PATHOLOGY. 

may  be  regarded  as  a  statement  in  pathology,  but  its  basis 
I  belongs  to  physiolog\\  The  mucus  is  practically  the  only  sub- 
1  stance  that  is  deposited  upon  the  ~g()ft  tissues.  This  deposit 
renders  these  tissues,  and  all  other  tissues  of  the  mouth  indeed, 
slippery,  and  in  this  way  performs  a  very  important  function. 
Maintenance  of  the  teeth  in  the  line  of  the  arch. 
A  second  function  of  the  gingivae,  perhaps  in  a  degree  a  part  of 
the  first,  is  the  maintenance  of  the  teeth  in  the  line  of  the  arch. 
Q^'he  influence  of  the  bone  forming  tlie  alveolar  process  has  been 
much  overrated  in  its  importance  in  maintaining  the  teeth  in 
their  positions.  Hard  and  rigid  as  the  bones  of  the  skeleton 
seem  in  the  dried  state,  bone  is  a  very  plastic  tissue  during  life, 
and  is  bent  about  in  almost  any  direction  by  a  constant  artificial 
pull.  In  the  treatment  of  clubfeet  I  have  seen  the  bones  of  the 
lower  leg  bent  much  out  of  their  normal  shape  by  a  compara- 
tively light  continuous  pull  upon  them.  This  was  effected  by 
light  rubber  straps  attached  to  the  upper  part  of  the  leg  by 
adhesive  plaster,  and  reaching  to  the  feet,  to  make  tension  in 
certain  directions.  When  these  straps  are  released  and  the 
muscles  and  nonmuscular  tissues  of  the  connective  tissue  group 
resume  their  functions,  these  bones  quickly  return  to  their 
normal  form.  The  bones  are  good  as  holding  against  a  stress 
suddenly  applied  and  then  released,  but  not  for  a  continuous 
stress  out  of  the  normal  directions.  This  is  especially  true 
when  there  is  an  interference  with  the  normal  action  of  the  soft 
tissues  for  the  time. 

When  a  lower  first  molar  is  extracted  at  a  certain  time  of 
life,  its  alveolus  is  filled  with  bone,  and  the  alveolar  process,  as 
such,  disappears.  The  gingivae  are  swept  away,  and  a  cicatricial 
tissue  is  formed  in  the  space  to  which  the  ends  of  the  fibers  of 
the  trans-septal  group  are  fastened.  The  shrinkage  of  this 
cicatrix  and  the  pull  of  the  trans-septal  group  of  fibers  drags  the 
second  and  third  lower  molars  to  the  mesial  and  tips  them 
mesially  until  their  occlusal  surfaces  do  not  meet  their  fellows 
correctly. 

These  teeth  are  literally  dragged  through  the  bone,  endwise 
of  the  bone,  where  there  is  no  possible  chance  for  the  bone  to  be 
bent  away.  The  solid  bone  must  be  moved,  or  when  it  can  not 
be  moved  in  substance,  it  will  be  moved  by  absorption  in  one 
direction,  and  building  in,  in  the  other.  It  will  not  stand  against 
a  connective  tissue  constancy  of  stress.  We  have  been  long  in 
finding  that  the  connective  tissue  group,  other  than  active 
muscles,  has  a  great  function  in  directing  the  building  of  the 


THE    GINGIVA.  29 

body,  holding  organs  in  their  places  in  health,  and  bringing  them 
back  to  place  when  the  correction  of  conditions  will  allow  them 
freedom  of  action.  These,  indeed,  are  the  most  active  of  the 
tissues  in  maintaining  the  phylogenetic  play  of  forces  in  shaping, 
trimming,  forming  and  maintaining  the  development  of  the  body 
in  its  general  ancestral  forms,  and  yet  with  the  finest  sense  of 
ontogenetic  development,  or  the  shaping  of  the  individual  in  all 
of  its  parts.  There  is  no  place  in  the  human  body  where  we  find 
as  fine  examples  of  this  play  at  control  of  form  by  the  non- 
muscular  connective  tissue  as  in  the  gingivae,  or  so  much  harm 
from  its  influence  when  the  conditions  have  given  them  a  wrong 
direction.  This  will  necessarily  come  into  discussion  often  in 
pathological  studies  of  the  influence  of  the  various  tissues. 


30  SPECIAL    DENTAL    PATHOLOGY. 


THE  CEMENTUM,  PERIDENTAL  MEMBRANE 
AND  ALVEOLAR  PROCESS 

ILLUSTRATIONS:    FIGURES  25-121. 

The  cementiim  and  peridental  membrane  and  the  correla- 
tion of  these  two  tissues  in  health  and  disease  are  of  the  highest 
degree  of  importance,  yet  of  all  of  the  dental  tissues,  these  are 
the  least  well  understood. 

It  is  quite  essential  that  one  should  have  a  clear  understand- 
ing of  the  physiology  of  the  several  tissues  of  the  teeth,  and 
their  physiological  and  pathological  relations  to  the  tissues  with 
which  they  are  directly  connected.  One  should  know  how  these 
act  and  react  toward  each  other,  the  limitations  of  their  powers 
in  recuperation  following  disease  or  accident,  and  the  more 
general  questions  along  this  line.  If  these  are  well  understood, 
it  will  be  comparatively  easy  to  comprehend  the  pathological 
conditions,  their  symptomatology,  and  wliat  may  and  what  may 
not  be  accomplished  in  treatment.  Knowledge  of  what  can  not 
be  done  is  as  important  in  practice  as  knowledge  of  what  can  be 
done.  Many  dentists  are  losing  time  and  prestige  in  trying  over 
and  over  again  to  do  things  which  the  history  of  cases  has 
demonstrated  to  ])e  impossible.  We  should  know  the  history  of 
these  efforts  and  failures,  and  their  meaning  in  pathology. 
Slowly,  possibly  very  slowly,  we  will  find  ways  to  do  things 
which  we  can  not  do  now.  We  should  ever  be  on  the  watch  for 
improvement,  but  should  be  very  careful  about  pinning  faith  to 
fancies  in  the  treatment  of  disease. 

Histological  studies  or  the  peridental  membrane.  In  the 
years  preceding  the  publication  of  the  American  System  of 
Dentistry  (1886),  there  was  considerable  speculation  as  to  the 
structure  of  the  peridental  membrane.  There  were,  however,  no 
studies  of  this  tissue  available  which  seemed  to  me  to  be  at  all 
sufficient,  or  which  bore  the  stamp  of  real  histological  work. 
When  I  was  called  upon  to  write  the  article  on  the  comentum 
and  peridental  membrane,  and  their  diseases,  for  that  publica- 
tion, I  undertook  the  histological  study  of  these  tissues  along 
with  other  work  with  which  I  was  unusually  busy.  When  my 
copy  was  otherwise  ready,  I  found  my  studies  of  the  histology 


CEMENTUM,   PERIDENTAL   MEMBRANE,    ALVEOLAR    PROCESS.         31 

SO  hopelessly  behind  that  I  wrote  a  very  short  description  of 
some  of  the  principal  features,  and  forwarded  my  copy  to  the 
printer.  But  others  were  so  far  behind  in  their  work  that  the 
final  completion  of  the  book  was  much  delayed.  In  the  mean- 
time I  had  found  the  facts  on  which  I  could  have  written  the 
histology  complete.  I  was  glad  to  find  later  that  my  short  and 
insufficient  description  of  the  membrane  contained  no  serious 
errors. 

My  later  studies  of  the  histology  of  the  peridental  mem- 
brane and  the  comparative  study  of  the  periosteum  in  different 
parts  of  the  body  were  embodied  in  a  series  of  articles  published 
in  the  Dental  Review,  beginning  witli  its  first  issue  in  November, 
1886,  and  continuing  in  1887  until  completed.  As  soon  as  tliis 
publication  was  completed,  the  copy  was  revised  and  published 
in  book  form  under  the  title  of  ''The  Periosteum  and  Peridental 
Membrane,"  1887.  Figures  27  to  42,  illustrating  the  growth  of 
connective  tissue,  and  Figures  47  to  65,  illustrating  the  growth  of 
bone,  are  reproduced  from  this  book.  Very  slowly  the  facts 
developed  in  these  studies  are  finding  their  way  into  our  better 
text-books,  as  yet  insufficiently  stated,  but  with  improvement  as 
the  years  go  by.  The  very  concise  statements  of  the  histological 
structure,  with  excellent  illustrations,  by  Dr.  F.  B.  Noyes,  in  his 
book  on  dental  histology,  published  in  1912,  are  assisting  mate- 
rially in  spreading  correct  information. 

During  the  past  few  years,  there  have  been  a  num]:)er  of 
articles  by  German  scientific  observers  relative  to  the  cellular 
elements  in  the  peridental  membrane.  Many  of  these  have  been 
written  by  able  histologists,  and  add  much  of  accurate  knowledge 
of  these  tissues,  both  in  their  normal  condition  and  in  their 
pathological  changes.  Reference  will  be  made  to  these  studies 
in  the  consideration  of  the  specialized  cells  of  the  peridental 
membrane  and  also  in  cyst  formation. 

The  Cementum. 

ILLUSTRATIONS:    FIOUUKS  43-92. 

The  cementum  covers  the  root  portion  of  the  tooth,  enclos- 
ing the  dentin,  and  usually  slightly  overlaps  tlie  gingival  portion 
of  the  enamel.  The  attachment  of  the  peridental  membrane  is 
therefore  to  the  cementum. 

The  cementum  is  a  speciali5;od  tissue.  Nothing  like  it  exists 
elsewhere  in  the  animal  body.  It  is  in  every  respect  a  passive 
tissue.     It  does  not  originate  any  form  of  physiological  activity. 


32  SPECIAL   DENTAL   PATHOLOGY. 

It  does  not  build  itself,  nor  repair  injuries  to  its  own  tissue. 
It  is  laid  down  on  the  dentin  by  the  peridental  membrane  very 
much  as  subperiosteal  bone  is  built  by  the  periosteum.  It  is 
much  like  bone,  and  has  in  its  substance  corpuscles  very  like  the 
bone  corpuscles.  Especially,  it  closely  resembles  subperiosteal 
bone  in  its  histological  content.  But  the  corpuscles  are  usually 
fewer  and  less  regularly  placed.  In  some  specimens,  however, 
the  cement  corj)uscles  are  plentiful.  In  this,  different  specimens 
vary  widely.  The  cementum  is  much  thicker  toward  the  apex  of 
the  root,  and  thins  away  toward  the  gingival  line,  which  it  forms 
by  lapping  slightly  on  the  margin  of  the  enamel. 

Differences  between  cementum  and  bone. 

The  point  in  which  cementum  differs  most  widely  from  bone 
is  in  the  absence  of  a  blood  vascular  system.  In  bone  every  part 
of  the  tissue  is  within  the  sphere  of  the  circulation  of  red  blood, 
and,  without  aid  from  adjacent  tissues,  is  subject  to  absorption 
and  perfect  rebuilding  of  its  own  tissues  at  any  time.  It  has 
this  power  within  its  own  tissue.  Also  subperiosteal  bone  is 
cut  away  by  absorption  and  rebuilt  as  Haversian  bone,  which 
has  numerous  channels  conveying  arteries,  veins  and  nerves.* 
(See  Figures  43,  44,  45  and  46.)  Cementum  has  none  of  these 
whatever.  It  has  no  circulation  of  red  blood  in  any  form.  It 
is  therefore  dependent  upon  the  peridental  membrane  for  the 
maintenance  of  the  life  of  its  cement  corpuscles. 

Cementum  does  not  eepair  injuries. 

Cementum  has  not  in  itself  any  power  of  repairing  injuries 
to  its  tissue.  When  stripped  of  its  peridental  membrane  it 
becomes  a  dead  tissue,  no  matter  if  the  pulp  of  the  tooth  is  alive. 
The  tissue  of  the  cementum  has  no  power  of  initiating  or  carry- 
ing forward  any  reparatory  process  whatever  in  the  absence  of 
the  soft  tissues  around  it,  or  when  these  have  been  parted  from 
it  by  suppuration. 

Cementum  subject  to  absorption. 

The  otherwise  normal  cementum  is  very  subject  to  absorp- 
tions. These  begin  upon  the  outside,  next  to  the  peridental 
membrane,  and  extend  inward  or  laterally  from  that  beginning. 
This  absorption  is  the  true  physiological  process  of  the  removal 
of  the  roots  of  the  deciduous  teeth  in  the  shedding  of  these  in 

*  "  The  Growth  of  Bone,"  by  William  Macewen,  F.R.S.,  published  in  Glasgow  in 
1912,  is  a  splendid  work  which  gives  a  much  broader  view  of  the  growth  of  bone  and 
its  powers  than  it  is  possible  for  me  to  give  here. 


Fig.  47. 


■jj^f-/ 


'^       ^ 


B 


?       / 

JS      ^         *      '  ^ 


r  It 


',  ^  (J,    -  (<<^> 


^ 


Fig.  48. 


Figs.  47  to  G5.     A  series  illiistratiiig  the  growth  of  bone. 

Fig.  47.  Non-attached  periosteum  from  the  sliaft  of  the  f.'iniir  of  the  kitten. 
B,  Bono,  o,  Layer  of  osteoblasts.  In  tlic  central  portion  of  the  figure  they  have  been 
pulled  slightly  awav  from  tiie  bone,  displaying  the  processes  to  advantage.  It  will 
be  observed  that  the  fibers  of  the  periosteum  do  not  enter  the  bone.  a.  Inner  layer 
of  fine  white  fibrous  tissue  (osteog.Mietic  layer)  showing  the  nuclei  of  the  fibroblasts 
and  a  number  of  developing  connective  tissue  cells,  which  probably  become  osteo- 
blasts, c,  Outer  layer,  or  coarse  fibrous  layer,  in  which  fusiform  fibroblasts  arc  also 
rendered  apparent  by  double  staining  with  hematoxylin  and  carmine,  il.  S.une  remains 
of  the  reticular  tissue  connecting  the  superimposed  tissue  with  tlie  |)cnostcuiii. 

Fig  48.  Attached  periosteum  from  beneath  the  attachment  of  tlie  muscles  of 
the  lower  lip  of  the  shee]).  a.  lione.  b.  Osteoblasts,  with  the  fibers  emerging  from 
the  bone  between  them,  c,  Inner  layer  with  fibers  decussating  and  joining  the  inner 
side  of  the  coarse  fibrous  layer  in  opposite  directions.  This  is  ratlier  an  unusual 
form  of  this  layer  of  tlio  ]ieriost.Mim.  p.  Coarse,  fibrons  layer,  v..  .XttachmiMit  of 
muscular  fibers. 


*4 


.  f  .IklilllUl 


Fig.  49. 


Fig.  50. 


Figs.  47  to  Go.     A  series  illustrating  the  growth  of  hone. 

Fig.  49.  Periosteum  from  the  shaft  of  the  tibia  of  the  pig,  lengthwise  section, 
showing  the  complex  arrangement  of  fibers  in  the  coarse  or  outer  fibrous  layer  which 
sometimes  occurs  under  muscles  that  perform  sliding  movements.  B,  Bone.  0,  Layer 
of  osteoblasts.  The  tissue  has  been  pulled  slightly  away  f>om  the  bone  in  mounting 
the  section,  and  part  of  the  osteoblasts  have  clung  to  tlie  bone,  some  have  clung  to 
the  tissues,  while  others  are  suspended  midway,  their  processes  ('linging  to  each, 
a,  Thayer  of  fine  fibers.  Inner  or  ostcogenetic  layer  of  the  periosteum,  b,  First  lamella 
of  the  coarse  or  outer  fibrous  layer,  the  fibers  of  which  are,  in  this  case,  circum- 
ferential, exposing  the  cut  ends.  It  will  be  observed  that  there  are  ten  lamella;  in 
the  make-iiji  ni'  tlie  outer  layer,  the  lengthwise  and  circumferential  fibers  alternating. 
Those  marked  f,  ;iiid  i,  arc  very  delicate  ribbon-like  forms,  whicdi  liave  shifted  from 
their  normal  position  in  the  mounting  of  the  section,  so  as  to  present  their  sides  to 
view  instead  of  their  ends,  thus  displaying  their  structure  to  advantage.  The  illus- 
tration shows  how  readily  separable  these  lamella?  are.     1,  Reticular  tissue. 

Fig.  50.  Periosteum  from  the  lower  end  of  the  femur  of  the  kitten  at  a  point 
where  the  enlarged  end  next  the  joint  is  being  trimmed  down  for  the  elongation  of 
the  shaft,  showing  the  fiVjers  of  the  periosteum  included  in.  or  entering  the  bone,  form- 
ing its  attachment,  also  the  absence  of  osteoblasts  and  the  presence  of  osteoclasts 
by  which  the  outer  portions  of  the  bone  are  Ijeing  removed.  I3.  Bone,  c,  Osteogenetic, 
or  inner  layer  of  periosteum,  d.  Outer  layer,  a  part  of  which  seems  to  have  been 
torn  away.  E,  A  few  circumferential  fibers,  f.  f,  f.  Osteoblasts  lying  in  the  lacunse 
of  Howship,  or  exca\!ition«  in  tlie  Imne  made  bj'  these  cells. 


/    1       »    .  '      ,  y'  I    P       ^      '>^  *  S-  •*"  f  ^       ">  '/  /' 


^ 


Fig.  51. 


Fig.  52. 

Figs.  47  to  65.     A  series  illustrating  the  growth  of  boue. 

Fig  11  The  more  usual  form  of  the  attached  periosteum  A,  ^""''•.  ^' ';;"^ 
the  i^^u^l-fibel:  (penetrating  tibers  of  ^^^^^  ^"^^ ^^ZX  ^  ' 
out  between  the  osteoblasts  b,  an.l  breaking  up  into  f '^f^  ';^5;.;,  '\  ,  b"okon  margins 
layer  of  the  periosteum.  These  are  also  seen  l'^"ti"f  "S/'"'",/.  "^^  ^ccur  mosth  in 
of^he  section  at  g,  g,  g.  d,  Blood  vessels  winch  are  cut  a«  -s  Phej  0  cu  no  t  .v^^^^ 
the  inner  layer,  veiy  close  to  the  under  side  ot  the  «^^'  '^  \\;^,/\',,,  Haversian 
bundles.     F,   Attachment   of   muscular   fibers.      ^^      lU   b     n  t  .u 

canals  at   h,   h,   h,    h.    nnd   nt    nth.'r    i-unts,   are   filling    u,.    u.th    h-.m 
residual  fibers. 


Fig.    52.      A    iiliotinnicrograph    of    an    alt;i<-lie<l     p 
From  the  alveolar  process  of  a  sheep.     Noycs. 


strum    similar    to    Fig.    51. 


*,# 


h^ 


4rr^  ^ 


// 


* 


■^% 


«!> 


^. 


Fig.  53. 


Ck_ 


"W 


^', 


V>'^ 


Fig.  54. 


Figs.  47  to  65.     A  series  illustrating  the  growth  of  bone. 

Fig.  53.  Bone,  with  portion  of  inner  layer  of  attached  periosteum,  and  pene- 
trating fibers.  The  section  is  cut  across  the  Haversian  canals,  and  it  shows  the 
manner  of  the  formation  of  these  in  the  surface  of  the  growing  bone  at  a,  a,  by  the 
upward  growth  of  spicula^  of  bone  which  then  spread  out  and  join  with  others,  thus 
bridging  over  and  forming  canals.  At  b,  b,  b,  b,  four  Haversian  canals  are  seen 
lined  with  osteoblasts.  Around  each  of  these,  fresh  bone  is  being  deposited,  which 
may  be  recognized  by  a  slight  difference  in  shade,  but  especially  by  the  fact  that 
the  bone  corpuscles  lie  in  a  difrcrent  position  from  others  in  their  neighborhood,  and 
the  fact  that  this  bone  has  no  residual  fibers.  It  should  be  noted  that  this  fonnation 
of  canals  immensely  increases  the  area  upon  which  osteoblasts  may  build. 

Fig.  54.  Bone,  with  a  more  solid  growth  of  surface,  and  with  osteoblasts  much 
crowded  between  the  fillers  of  the  periosteum  as  they  emerge  from  the  bone.  Only  a 
])art  of  the  inner  layer  of  periosteum  is  shown,  a,  a,  Osteoblasts  several  layers  deej) 
between  the  fibers  of  the  ]ieri()steum.  b.  b,  S])iculir  of  bone  growing  uji  into  the 
periosteum,  apparently  following  the  line  of  a  particular  fiber,  c,  Haversian  canal 
that  seems  to  have  been  excavated  in  the  bone,  and  is  Ix'ing  filled  by  deposit  of  new 
bone  on  its  walls.  This  new  deposit  of  bone  is  distinguished  by  a  somewhat  lighter 
shade,  and  the  difference  in  the  direction  of  the  long  axis  of  the  bone  corpuscles,  and 
the  absence  of  residual  fibers.  Osteoblasts  appear  in  this  portion  of  the  canal.  The 
margins  of  the  secondary  formation  show  the  bay-like  forms  usual  in  the  absorption 
of  bone.  Above  the  line  drawn  at  E,  no  secondary  bone  is  found,  and  osteoclasts, 
g,  g.  are  seen  instead  of  osteoblasts.  In  this  portion  the  excavation  is  going  on. 
In  this  way  the  bone,  with  residual  fibers,  is  removed  and  bone  deposited  in  which 
these  do  not  appear. 


'I    , 


Fig.  55. 


',  -'f 


S^:^ 

-^f:"^ 


^^^m^ 


Fig.  56. 


Figs.  47  to  65.     A  series  illustrating  tlie  growth  of  bone. 

Fig  55  Margin  of  growing  bone  upon  whieli  the  osteoblasts  are  very  mucli 
crowdecL  a.'  Osteoblasts  reaching  to  the  surface  of  the  bone  by  extemliug  proccss_ 
like  i.roh.ngations.  b,  A  cell  that  seems  to  be  flattening  down  upon  the  surface  of 
the  bono,  c,  Bone  corpuscles,  the  processes  of  which  are  seen  ra.luit.ng  in  the  bone 
matrix.    Processes  are  also  seen  extending  into  the  l)one  from  some  of  the  osteoblasts. 

Fig  56.  Cross  section  of  a  young  growing  bone,  showing  the  Haversian  canals 
and  the  plan  of  their  subperiosteal  formation,  a,  Outer  layer  of  periosteum,  b,  inner 
layer  of  periosteum,  c,  c,  Spicula>  of  bone  growing  outward  into  the  tissue  ot  the 
inner  layer  of  periosteum,  d,  Other  and  older  spicula-  spreading  out  at  their  summits, 
fr,rming  i.ortions  of  arches,  e.  Other  spieuUv,  the  arches  of  which  :.re  about  closing 
to  form  Haversian  canals,  f.  Complete  Haversian  canals,  many  of  which  are  so.-n  in 
the  illustration. 


^ir^  2''^\ 


Fig.  57. 


Fig.  58. 


Figs.  47  to  65.     A  series  illustratiug  the  growth  of  bone. 

Fig.  57.  Absorption  of  bone  under  attached  periosteum,  a,  a,  Osteoclasts  lying 
in  deep  excavations  in  the  surface  of  the  bone,  b,  b.  Surface  of  l)one,  showing  the 
fibers  of  the  periosteuni  implanted  in  it.  Eesidual  fiber.s  appear  in  the  bone.  It  will 
be  noted  that  these  fibers  are  removed  with  the  bone  by  the  absorptive  process, 
c,  c,  Masses  of  embryonic  tis.sue  filling  the  areas  formed  by  the  absorption. 

Fig.  58.  Intra-membranous  formation  of  bone.  An  island  of  bony  deposit, 
a,  a,  Bone  corpuscles.  1),  b,  Osteoblasts.  It  will  be  seen  that  these  lie  between  the 
fibers  of  the  membrane,  so  that  in  certain  positions  the  osteoblasts  lie  with  their  ends 
to  the  forming  bone.  For  the  most  part  the  long  axes  of  the  bone  corpuscles  have  a 
siniilar  direction. 


'f.^.ff 


v^      ^ 


)     •    i.      "        '''       '      -' 


^X.  «/  .\<'^,-^(. . 


111? H flu     i  ?l!f ; 


^'iiiilt 


Fig.  59. 


<^ 


■  -./ 


Figs.  47  to  65.     A  series  illustrating  the  growth  of  bone. 

Fig.  59.  Growth  of  bone  under  the  attachment  of  the  Tendo  Aehillis  in  a  young 
lamb.  A,  Fibers  ff&  tendon  partially  converted  into  fibro-cartilage.  The  cartihage  cells 
are  seen  mostly  between  the  tendon  fibers.  B,  b,  and  c,  e,  c,  Canals  advancing  from 
the  bone  beneath  into  the  tendon,  d,  d,  d,  Bone  deposited  upon  the  walls  of  the  canals 
forming  Haversian  systems  laid  upon,  or  among  the  tendon  fibers.  E,  Portions  of  the 
tendon  fibers  still  remaining  deep  among  the  Haversian  systems  of  bone. 

Fig.  60.  A,  Single  canal  as  shown  at  b,  Fig.  59,  very  much  enlarged,  a,  a,  Car- 
tilage, b,  b,  Tissue  of  canal,  c,  Blood  vessel,  d,  d,  Bone,  e,  e,  Osteoblasts,  f,  f, 
Chondroclasts.  Tn  both  these  figures  the  bay-like  excavations  of  the  absorption  cells 
are  seen  in  the  caTials,  iind  at  the  margins  of  the  bone  deposited  in  these. 


. ■rtoa>'.«^  ^''     **'     **'  » 


FiQ.  61. 


Figs.  47  to  65.     A  series  illustrating  the  growth  of  bone. 

Fig.  61.  The  changes  Avhich  occur  in  diaphysial  intra-cartilaginous  formation  of 
bone,  a,  Cartilage  nnciiaiigod.  At  b,  the  colls  have  become  smaller  and  have  fallen 
into  rows.  At  c,  the  cells  are  enlarged  in  their  short  diameters,  or  in  the  direction 
of  the  length  of  the  shaft  of  the  bone.  At  n,  the  growth  of  tiie  cells  has  reached  its 
limit.  The  matrix  begins  to  calcify.  At  E.  the  capsules  of  the  cells  are  opened  by 
the  advance  of  the  absorbent  tissue,  f,  Area  of  tlie  formation  of  bone,  g,  Appar- 
ently some  glutinous  remains  of  the  cell  body  clinging  to  the  walls  of  the  capsule, 
h,  Small  round  marrow  cells,  p,  p.  p.  Remains  of  tlie  cartilage  matrix,  j,  Osteo- 
blasts applied  to  the  remains  of  cartilage  matrix,  but  no  bone  is  seen.  K,  K,  K,  Osteo- 
blasts and  a  layer  of  bone  deposited  on  the  remains  of  cartilage  matrix,  m,  m,  m,  m. 
Blood  vessels,  n,  Capsule  which  seems  to  have  been  just  opened  and  the  marrow 
cells  seen  in  the  act  of  crowding  into  it.  o.  Fusiform  cells.  Many  of  these  appear 
in  this  portion  of  the  figure,  and  seem  jieculiar  to  this  location. 


it'^^  l.^»K 


Figs.  47  to  65.     A  sprirs  i  I  lust  rating  tlu'  yiowtli  of  hour. 

Fig.  62.  (Vtitral  section  of  the  licad,  and  [.ortioii  of  tlic  shaft,  of  tlio  tibia  from 
young  kitten,  Hin)\vinfj  (liMjiliyKial  intra  caitiiayinons  formation  of  the  bono  at  d,  and 
the  beginninfj  of  tlie  eiJipiiysial  at  ii.  a,  ("artilaiiinons  iiead  of  bone,  b,  b,  Periosteum, 
c,  c,  Layer  of  subperiosteal  bone,  e,  Periosteal  notcli ;  tlie  point  to  which  the  sub- 
periosteal formation  of  bone  extends,  f,  Beginning  of  change  in  the  cartihige  cells 
where  they  form  rows,  g,  Line  of  absorption  of  the  cartilage.  At  d,  the  darkened 
portion  reaching  up  to  the  line  g,  shows  the  portion  occupied  by  the  boue  marrow,  and 
the  light  portions  the  bone  formed. 

Fig.  63.  Supplement  to  Fig.  61.  taken  from  another  portion  of  the  section  and 
showing  the  marrow  cells  applied  closely  to  the  walls  of  the  capsules  next  to  be 
opened,  a.  Cartilage,  b,  Fusifortn  cells  filling  closely  the  last  capsule  opened  iu  that 
row.  c,  c,  Round,  marrow  cells  filling  other  (•ai)snles  in  tin-  same  manner,  d.  Unab- 
sorbed  remains  of  cartilage  nmtrix. 


Fig.  64. 


Fig.  65. 


Figs.  47  to  65.     A  series  illustrating  tlie  growth  of  bone. 

Fig.  64.  Epipliysial  intra -cartil.'igi nous  formation  of  bone  fidrii  licjul  of  tibia  of 
young  lamb.  a.  a,  Cartilage,  the  cells  of  which  have  fallen  into  rows,  but  have 
become  scattered  between  the  letters  a,  ami  b,  b.  b.  b,  Haversian  canals  advanced 
from  the  bone  into  the  cartilage.  Tt  should  be  noticed  that  these  are  lined  with 
chondroclasts  where  tiie  absorption  of  cartilage  is  in  j)rogress,  and  with  osteoblasts 
when  bone  is  being  de])osited.  (".  Blood  vessels,  d,  d,  d,  Bone,  which  is  extended 
into  the  cartilage  by  the  filling  of  the  canals  formed  by  absorption  as  shown  at  e. 

Fig.  6").  From  a  cross  section  of  a  rib  of  a  young  kitten  at  a  little  distance 
(boneward)  from  the  change  from  cartilage  to  bone  sliowing  the  large  Haversian 
canals  with  the  remains  of  the  cartilage  matrix  enveloped  in  the  bone  formed. 
a,  a,  a,  a,  Kemains  of  cartilage  matrix,  which,  in  the  figure,  is  left  white,  b,  b,  b,  b. 
Bone  deposited  on  remains  of  caitilage  matrix,  ami  generally  covered  with  osteo- 
blasts, but  at  c,  c,  c,  c,  and  other  points,  osteoclasts  are  quite  plentifully  distributed. 
While  in  one  part  bone  is  being  deposited,  in  another  it  is  being  removed,  and  in  the 
end  all  the  cartilage  matrix  disappears. 


Fig.  66. 


Fig.  6(d.  A  photomicrograph  of  a  portion  of  the  root  and  ppridpntal  iiiftmbranp 
of  a  tooth  in  wiiic'h  an  absorption  iias  boon  repaired  by  a  new  ^irowth  of  eenientum. 
D,  Dentin,  c,  C'eiiieiituni.  i",  Pcrii|<>ntal  membrane.  R,  New  cemeiitum  built  in,  in 
repair  of  an  injury  by  al)siirptii)ii. 


Fig.  67. 


Fig.  67.  Photomicrograph  of  a  cross  section  of  tiie  root  of  a  tooth  in  which 
absorption  is  in  progress,  a,  Line  of  absorption,  showing  the  usual  notched  appear- 
ance known  as  the  hicuna>  of  Howship.  d.  Dentin,  c,  Cenientum.  p,  Peridental 
membrane.  The  pulp  chamber  appears  in  the  left-hand  part.  The  dento-ccmental 
junction  ap]>oars  between  the  letters  c  an<i  D. 


CEMENTUM,    PEKIDENTAL    MEMBEANE,    ALVEOLAR    PROCESS.         33 

order  that  the  permanent  teeth  may  take  their  places.  During 
the  absorption  of  the  roots  of  the  deciduous  teeth,  it  often  occurs 
that  a  beginning  absorption  is  repaired  by  the  deposit  of  new 
cementum  by  the  cementoblasts  of  the  peridental  membrane,  fill- 
ing up  the  breach  made,  either  partially  or  completely.  These 
repairs  often  occur  after  the  absorption  has  penetrated  the 
dentin  to  considerable  depths.  No  matter  what  the  depth  of  tlie 
absorption  in  dentin,  the  repair  of  the  whole  depth  is  always 
made  by  a  deposit  of  cementum,  never  by  building  in  dentin. 
(See  Figures  66  to  74.)  There  is  nothing  like  an  inflammatory 
movement  connected  with  these  absorptions.  They  are  always 
effected  by  the  formation  of  an  aggregation  of  specialized  cells, 
the  cementobla.sts.  They  do  not  differ  materially  from  absorp- 
tions elsewhere  in  the  body,  as  in  the  bones.  In  the  bones, 
absorptions  for  the  formation  of  new  Haversian  canals  may 
always  be  found  in  progress  in  young  subjects.  The  characters 
of  the  cellular  groups  effecting  the  absorption  seem  to  be  much 
the  same,  whether  the  results  of  the  absorption  be  regarded  as 
physiological  or  pathological. 

Absorption  of  roots  of  permanent  teeth. 

Absorptions  of  portions  of  the  cementum,  often  penetrating 
into  the  dentin  also,  occasionally  occur  in  the  roots  of  the  perma- 
nent teeth.  In  part,  this  may  be  regarded  as  normal.  In  the 
movements  of  the  teeth  which  occur,  for  instance,  because  of  the 
loss  of  one  of  their  number,  the  fibers  of  the  peridental  mem- 
brane are  sometimes  cut  away  over  a  space,  and  a  part  or  all  of 
the  cementum  removed,  and  possibly  some  part  of  the  dentin 
also.  When  the  movement  of  the  tooth  has  been  accommodated, 
the  space  will  again  be  covered  with  new  cementum,  into  which 
the  principal  fibers  of  the  peridental  membrane  will  again  be 
attached.  This  can  not  be  regarded  as  pathological.  Much 
more  generally  these  movements  are  aecommodated  by  changes 
in  the  alveolar  walls. 

A  pathological  absorption  of  the  roots  of  the  i)ermanent 
teeth  occasionally  occurs,  though  at  rare  intervals.  I  have  seen 
two  cases  in  which  practically  all  of  the  teeth  of  the  persons 
were  lost  in  middle  life  from  absorption  of  their  roots.  In 
neither  of  these  cases  were  there  other  symptoms  than  the 
loosening  of  the  teeth. 

Cases  in  which  local  absorptions  in  the  roots  of  the  perma- 
nent teeth  occur  are  not  so  very  rare.  Any  one  who  is  extract- 
ing many  teeth  will  soon  be  rewarded  by  finding  some  of  these 


34  SPECIAL  DENTAL   PATHOLOGY. 

absorptions,  if  he  will  carefully  clean  the  teeth.  Some  will  be 
broad,  others  small  areas  of  not  considerable  depth.  Others 
will  be  very  small  in  area,  but  deep,  looking  as  much  like  worm 
holes  as  can  be  imagined.  Some  of  these  little  holes  may  reach 
the  pulp  canal.  Occasionally  an  absorption  reaches  the  pulp 
chamber  of  a  molar  tooth.  It  is  comparatively  rare  that  these 
absorptions  cause  pain.  I  have,  however,  seen  a  few  cases  in 
which  absorptions  invading  the  pulp  chamber  did  give  great 
pain,  which  was  referred  so  indistinctly  and  to  so  many  localities 
that  it  was  by  mere  chance  that  I  found  them. 

While  these  absorptions  occurring  within  the  substance  of 
the  root  of  the  tooth  may  be  repaired,  so  long  as  they  remain 
covered  by  the  peridental  membrane,  and  are  not  infected,  it 
does  not  follow  that  this  may  occur  if  the  membrane  has  been 
loosened  bj^  suppuration,  or  even  if  freely  exposed  to  the  ingress 
of  the  fluids  of  the  mouth  by  which  they  become  infected.  These 
questions  will  be  considered  later. 

Attachment  of  principal  fibers  of  the  peridental  membrane 
TO  the  cementum. 

The  principal  fibers  of  the  peridental  membrane,  which 
secure  the  tooth  in  position,  are  attached  to  the  cementum  by 
being  built  around  their  ends  with  cementum,  and  by  the  calcifica- 
tion of  their  ends  while  the  cementum  is  being  laid  down.  This  is 
accomplished  by  the  layer  of  cells  known  as  cementoblasts,  which 
perform  the  same  function  in  the  building  of  the  cementum  that 
the  osteoblasts  perform  in  the  building  of  bone.  By  some  spe- 
cial modes  of  preparing  specimens  for  microscopic  study,  these 
fibers  penetrating  into  the  cementum  are  brought  into  view. 
(See  Figures  75,  76,  77  and  78.)  In  many  cases  it  is  easy  to  find 
areas  from  which  the  fibers  have  been  cut  away  by  absorption, 
and  later  reattached  in  a  new  layer  of  cementum. 

Cementum  continuous  growing. 

The  cementum  is  in  a  sense  a  continuous  growing  tissue. 
It  is  always  thin  on  the  roots  of  the  child's  teeth  and  becomes 
thicker  as  the  person  grows  older ;  often  it  becomes  very  thick 
in  old  nge.  (See  Figures  79  and  80.)  It  is  deposited  in  layers 
which  are  similar  to  the  layers  of  subperiosteal  bone,  but  in  the 
building  of  cementum  these  layers  are  deposited  one  upon  the 
other,  always  increasing  the  thickness  of  cementum  as  they 
are  laid  down.     Each  layer  represents  a  new  deposit  of  calcific 


CEMENTUM,   PEEIDENTAL   MEMBRANE,   ALVEOLAR   PROCESS.        35 

material.     In  this  way  we  may  count  a  large  number  of  layers 
in  the  elderly  person,  but  not  so  many  in  the  young  person. 

Hypercementosis. 

Extraordinary  growth  of  cementum  appears  frequently, 
producing  what  is  known  as  hypercementosis.  In  this  condition 
the  root  ends  are  liable  to  grow  larger  and  larger  by  deposits 
of  cementum.  Layer  after  layer  may  be  found  in  Home  par- 
ticular portion  of  the  root,  most  frequently  on  the  end ;  or  if  the 
roots  of  two  teeth  are  lying  closely  together  in  the  iDone,  they 
may  be  united  by  this  extra  deposit  of  cementum.  In  three  or 
four  instances  I  have  seen  three  teeth  with  the  roots  united  in 
this  way.     (See  Figures  81  to  92.) 

In  sections  of  such  cementum  a  considerable  number  of 
absorption  areas  that  have  been  filled  over  with  other  layers  of 
cementum  may  generally  be  seen.  In  studying  cases  of  growth 
of  cementum  we  find  a  considerable  deviation  from  the  normal 
thickness  and  contour  of  the  tissue,  which  can  only  be  explained 
when  one  understands  the  nature  of  the  growth ;  how  layer  upon 
layer  may  be  laid  down  and  absorbed  again  and  any  part  of 
these  absorptions  filled  in.  These  frequent  absorptions  and 
rebuildings  might  at  first  seem  to  be  without  order  of  construc- 
tion, and  yet  as  we  come  to  understand  them  we  appreciate  that 
they  are  brought  about  in  a  natural  and  orderly  way. 

Cementum  in  animals. 

The  cementum  in  the  lower  animals  is  similar  in  most 
respects  to  that  of  man.  Physiologically  there  seems  to  be 
no  difference.  Certain  differences  in  form  and  thickness  are 
observable.  As  a  rule  the  cementum  of  the  carnivora,  as  cats, 
dogs,  etc.,  is  rather  thinner  than  in  man. 

In  the  omnivorous  animals,  and  especially  in  the  hog,  the 
cementum  is  very  thick  and  heavy  and  is  generally  well  devel- 
oped. As  seen  in  sections,  its  layers  are  generally  well 
arranged,  numerous,  and  the  cement  corpuscles  are  large,  with 
as  full  a  complement  of  fibrils  as  will  be  found  in  the  bones.  Yet 
in  this  splendid  development  of  cementum  there  is  no  sign  what- 
ever of  circulation  of  red  blood.  For  the  best  studies  of  these 
features  an  adult  animal  should  be  had.  If  it  is  growing  a  bit 
old,  it  is  still  better.     (8ee  Figures  7G,  77  and  78.) 

In  the  strictly  herbivorous  animals  the  thickness  of  the 
cementum  lies  between  these  extremes  and  is  more  like  that  of 
man.     There  is  no  essential  difference  in  the  type  of  the  tissue. 


36  special  dental  pathology. 

The  Pekidental  Membrane. 

ILLUSTRATIONS:    FIfiURES  93-116. 

The  term  peridental  membrane  is  ap])liecl  to  the  soft  tissue 
located  between  the  root  of  the  tooth  and  the  bony  walls  of  its 
alveolus,  or  socket.  These  membranes  serve  to  attach  the  teeth 
to  the  bones  of  the  jaws. 

The  peridental  membrane  is  a  very  active  tissue,  having  a 
rich  vascular  system  and  a  rich  supply  of  nerves.  It  is  subject 
to  inflammations  and  suppurations  as  these  occur  in  other  soft 
tissues.  It  is  able  to  repair  injuries  to  its  own  tissue,  but  does 
not  rebuild  its  own  tissue  when  any  considerable  part  of  this  is 
detached  from  the  cementum  by  suppuration.  If  the  peridental 
membrane  is  cut  from  the  tooth  as  closely  as  possible  with  a 
sharp  lancet,  as  may  readily  be  done  in  that  part  above  the  crest 
of  the  alveolar  process,  apparently  perfect  healing  occurs  very 
rapidly,  provided  there  is  no  infection.  The  tendency  of  the 
tissue  to  come  into  apposition  when  cut,  as  has  been  mentioned, 
is  a  powerful  influence  for  the  prevention  of  infection  in  such 
cuts. 

In  order  to  test  this  proposition,  I  at  one  time  tried  the  plan 
of  cutting  the  membrane  in  this  way  for  depletion  in  cases  of 
threatened  apical  pericementitis.  In  nearly  one  hundred  cases, 
there  were  but  two  that  did  not  heal  by  first  intention.  They 
seemed  to  be  completely  restored  in  one  or  two  days.  The  two 
cases  were  infected  and  suppuration  occurred,  vdiich  left  perma- 
nent injuries  in  the  form  of  shortened  gingivu\  This  occurred 
in  spite  of  my  care  to  clean  the  parts  well  before  making  these 
cuts. 

Fibers  op  the  peridental  membrane. 

The  peridental  membrane  has  a  special  arrangement  of 
fibers,  called  the  principal  fihcrs,  which  are  attached  to  the  tooth 
on  the  one  side,  and  to  the  alveolar  process  on  the  other.  (See 
Figures  99,  100  and  101.)  There  are  other  groups  of  these 
fibers;  the  free  gingiva  group,  which  extend  occlusally  into  the 
free  gingivae;  the  trans-septal  group,  which  pass  from  tooth  to 
tooth  over  the  crests  of  the  alveolar  septi ;  and  the  alveolar  crest 
grou]),  which  jiass  outward  from  tlie  cementum  and  are  attached 
into  tlie  crest  of  the  alveolar  process.  These  latter  groups  were 
described  in  our  consideration  of  the  gingiva^.    Within  the  peri- 


Fig.  08. 


Fig.  69. 


Fig.  68.  Roi'ord  in  the  calcified  tissue  of  an  absorjitiDn  i('|.ain'il:  i».  Dentin, 
cm,  Cementum  filling  absorption  cavity.     Nnt/rs. 

Fig.  09.  Thick  lamella?  of  cementum  witli  mnnv  lacunu',  lilliiifr  an  absorption  in 
dentin:     i..  Lacuna',     ii,  Howship's  lacuna-  filled,     d,'  iHnliii.     Ao/y.v. 


^ 


s:  ^r^ 


7        7        ^9 


Fig.  70. 


Fig.  70.  Cross  section  of  the  root  of  a  temporary  incisor  tooth  of  the  pig,  show- 
ing a  large  area  of  absorption  which  is  partly  filled  in  with  cementum. 

a,  Dentin,  b,  b,  Cementum.  c,  c,  Area  of  absorption.  It  will  be  noticed  that  in 
this  area  all  of  the  cementum  and  a  considerable  portion  of  the  dentin  have  been 
removed,  d,  d,  Cementum  that  has  been  laid  down  upon  the  surface  of  the  dentin 
and  cementum  alike,  e,  e,  I'eridental  membrane,  f.  Portion  of  bone  forming  the 
wall  of  the  alveolus  that  has  grown  forward  into  the  area  of  absorption,  g,  g,  Osteo- 
clasts which  are  removing  these  bony  projections.  The  bone  wliich  has  been  advanced 
here  to  take  the  place  of  the  absorbed  area  is  being  removed  again  in  compliance 
with  the  rebuilding  of  the  cementum,  which  is  in  progress. 


Fifi.  71. 


Fig.  72. 


I'u,.  7  1.  Djiriial)  ul  tlic  aiR'X  of  thr  root  of  a  lower  molar.  From  a  dry  soc- 
tiou.  a,  Pulp  canal,  b,  Dentin,  c,  Cenioutuni.  A  nuiiiber  of  absorptions  havo 
occurred  at  d.  Absorptions  have  proceeded  from  the  second  lamella  of  the  cemcntum 
and  have  penetrated  the  dentin  to  a  considerable  depth.  These  have  been  refilled 
with  a  somewliat  irregular  deposit  of  cemcntum.  Along  the  line  e,  a  very  considerable 
absorption  has  cut  away  the  entire  apex  of  the  root,  removing  not  only  the  cementum, 
but  evidently  a  considerable  portion  of  the  dentin  as  well.  From  the  appearance  of 
the  incremental  lines,  this  seems  to  have  occurred  contemporaneously  with  those 
pointed  out  at  d.  The  exposed  dentin  has  been  again  covered  with  cementum,  which  is 
fairly  regular,  though  its  incremental  lines  are  not  clear,  f.  .\n  absorption  that 
seems  to  have  been  in  progress  at  the  time  of  extraction. 

Fig.  72.  \n  nii]>cr  centnil  incisor  showing  an  absorption  of  a  portion  of  the  root. 
.Specimen   from    Nuilliui'strrn    I'liixci-sity    I)i'iit;\l    Mii-^cinn. 


/t*f*Vr-r>*>rr-Sf_<.  '^^  »,^        >>'./    ^.-^      ^TrfS.- 


^ 


Fig.  73. 


•>  .>v„j?^.'     ■  ^;,. '7"  ■■■v.    "it.:-*^-^-- ■ / 


^.^  <-:  V^u 


Fig.  74. 


Fl(i.  Vo.  From  a  sect  ion  of  a  hicu'^iiiil  with  its  aivcolus.  sliowiiig  a  pit-like 
absorption  upon  the  si<io  of  tlu'  root  in  \vhi<li  tiic  ri-dcposit  of  the  cenientum  has 
bogun.  a.  Dentin.  I),  ( 'enicntuni.  c.  I'cridcntal  nicnihrano.  d.  Bone  forming  the 
wall  of  the  alveolus,  e.  Absorbed  area  of  eementuni.  It  will  be  noticed  that  a  new 
fleposit  of  cementum  has  begun  the  filling  of  the  aiea,  and  that  the  soft  tissue  in  the 
area  of  absorption  is  of  a  cellular  type.  The  bone  also  shows  the  effects  of  absorp- 
tion in  the  cutting  awav  of  portions  of  the  rings  of  the  Haversian  systems  at  f,  while 
at  g  the  presence  of  osteoclasts  shows  that  absor[ition  is  in  progress  at  that  point. 

Fig.  74.  Cross  section  of  the  immediate  apex  of  the  root  of  a  cuspid  tooth, 
showing  large  areas  of  absorption,  a,  Root  canal,  b,  e.  g,  and  j  show  extensive 
absorption  areas  that  have  Ijeen  refilled  with  cementum,  while  c,  d,  h,  and  k  show 
smaller  absorption  areas  that  have  occurred  later.  Some  of  these  areas  show-  the 
included  fibers  of  the  peridental  membrane  plainly,  while  others  do  not,  probably  for 
the  reason  that  the  section  is  not  parallel  with  them.  At  f,  the  original  or  regular 
deposit  of  cementum  reaches  the  present  surface.  The  plane  of  the  section  is  not 
such  as  to  show  the  incremental  lines,  and  therefore  the  relation  of  the  absorptions 
to  these  can  not  be  seen. 


THE    PERIDENTAL    MEMBRANE.  37 

dental  membrane  proper  there  are  three  groups  of  fibers  which 
deserve  particular  mention,  as  follows : 

The  horizontal  group,  consisting  of  those  fibers  wliicli  i)ass 
out  at  right  angles  to  the  long  axis  of  the  tooth,  and  are  attached 
to  the  bone  of  the  alveolar  process  a  little  below  the  crest. 

The  oblique  group,  consisting  of  those  fibers  which  pass 
from  the  cementum  in  an  oblique  direction  occlusally,  and  are 
attached  to  the  bone  of  the  alveolar  process.  These  constitute 
the  body  of  the  peridental  membrane,  or  the  fibers  which  cover 
the  main  body  of  the  root  portion  of  the  tooth. 

The  apical  group,  consisting  of  those  fibers  which  are 
attached  about  the  apical  portion  of  the  root  and  extend  in  fan- 
shaped  bundles  to  the  surrounding  alveolar  process. 

It  is  the  function  of  these  three  groups  of  fibers,  assisted  in 
some  degree  by  the  groups  heretofore  described,  to  maintain  the 
tooth  in  its  socket  and  support  it  against  the  stress  of  mastica- 
tion. In  writing  of  these  groups,  I  shall  continuall}^  speak  of  the 
fibers  as  arising  from  the  cementum  and  being  attached  to  the 
bone.  We  might  just  as  consistently  speak  of  them  as  arising 
from  the  bone  and  being  attached  to  the  cementum. 

The  horizontal  group.  The  fibers  of  this  group  are 
placed  close  to  the  crest  of  the  bony  alveolar  process  and  pass 
directly  from  the  cementum  to  the  bone  and  are  attached  to  it. 
This  is  not  a  broad  band  of  fibers,  but  varies  considerably  in 
different  specimens.  Sometimes,  in  the  incisor,  cuspid  and 
bicuspid  regions,  we  will  find  this  band  of  fibers  about  as  broad 
as  one-half  the  thickness  of  the  tooth.  The  fibers  are  compara- 
tively short,  but  very  strong.  The  demarcation  between  this 
group  of  fibers  and  the  alveolar  crest  group  is  not  at  all  definite, 
but  the  fibers  of  this  group  pass  directly  across  and  are  inserted 
in  the  wall  of  the  alveolar  process  near  the  crest,  while  those  of 
the  alveolar  crest  group  are  inserted  into  the  margin  or  crest  of 
the  alveolar  process  and  have  a  somewhat  curved  direction.  It 
st^ms  to  be  tlie  function  of  the  horizontal  groii])  to  sustain  the 
tooth  against  sudden  lateral  pressure,  which  may  occur  in  the 
chewing  of  food.  It  is,  tlierefore,  a  very  imi^ortant  grou))  of 
fibers.  This  group  is  very  materially  assisted  in  sustaining  the 
tooth  against  lateral  pressure  by  those  fibers  of  the  apical  group 
which  pass  in  tlie  horizontal  direction,  and  tend  to  ])revent  lat- 
eral motion  of  the  apex  of  the  root.     (See  Figures  i)3, 1)4  and  !)5.) 

The  oblique  group.  The  fibers  of  this  group  constitute  the 
body  of  tlie  peridental  membrnne.  Jnst  apically  of  the  horizon- 
tal group  there  is  an  almost  sudden  change  in  the  direction  of 

*5 


38  SPECIAL   DENTAL   PATHOLOGY. 

fibers.  They  pass  across  in  an  oblique  direction  occlusally  from 
the  cementum  to  the  bone.  These  fibers  vary  much  in  their 
length  and  some  are  much  more  oblique  than  others.  They  are 
gathered  into  bundles,  more  or  less;  some  of  the  bundles  are 
short,  passing  almost  directly  across,  while  others  are  long, 
passing  quite  a  distance  occlusally  within  the  peridental  mem- 
brane before  they  reach  the  bone. 

This  description  applies  to  the  peridental  membrane  in  a 
young  person  or  young  animal.  As  the  person  or  animal  grows 
older,  and,  particularly,  when  the  teeth  have  been  subjected  to 
very  severe  use,  the  peridental  membrane  will  become  very  much 
thinner  and  the  blood  vessels  will  come  to  lie  in  grooves  in  the 
alveolar  process,  so  that  the  spaces  between  the  blood  vessels  are 
fully  studded  with  the  fibers  of  the  peridental  membrane 
throughout  this  body  portion  of  the  bone.  Such  teeth  are  unusu- 
ally firm  in  their  sockets  and  will  bear  great  pressure  without 
injury. 

Many  complete  bundles  of  fibers  can  be  traced  from  the 
cementum  to  the  bone ;  many  of  them  can  not  be  so  traced,  the 
fibers  seem  to  split  up  into  finer  fibers  and  re-collect  into  bundles 
for  insertion  into  the  bone.  This  arrangement  is  maintained, 
with  considerable  variation,  however,  over  the  body  of  the  root 
of  the  tooth. 

The  blood  vessels,  which  pass  from  the  position  of  the  apex 
of  the  root,  through  the  peridental  membrane  in  the  occlusal 
direction,  lie  almost  centrally  between  the  root  and  alveolar  pro- 
cess in  young  subjects.  These  very  much  disturb  the  apparent 
direction  of  the  fibers.  In  many  microscopic  sections  the  mem- 
brane has  the  appearance  of  being  double,  one  portion  being 
attached  to  the  cementum  of  the  tooth,  the  other  portion  to  the 
bone,  divided  by  the  blood  vessels.  The  presence  of  the  blood 
vessels  throws  the  fibers  out  of  the  field  in  the  particular  part 
of  the  section,  but  wherever  we  can  cut  a  section  through  the 
length  of  these  fibers,  undisturbed  by  the  passage  of  blood  ves- 
sels, the  idea  that  the  membrane  is  double  is  completely  dis- 
pelled. We  are  able,  then,  to  trace  the  fibers  from  the  cementum 
to  the  bone,  even  though  they  are  very  long.  (See  Figures  94 
and  95.) 

The  function  of  these  fibers  is  to  swing  the  tooth  in  its  socket 
and  sustain  it  against  pressure  coming  on  the  occlusal  surface 
or  the  incisal  edge  of  the  tooth.  These  fibers,  about  many  molar 
roots,  are  sufficiently  strong  to  maintain  the  tooth  against  three 


THE    PERIDENTAL    MEMBRANE.  39 

hundred  or  more  pounds  of  pressure,  which  gives  an  apprecia- 
tion of  their  combined  strength  in  supporting  the  teeth.  Bicus- 
pid and  moUir  teeth  which  are  unahle  to  sustain  a  stress  of  a 
hundred  pounds  or  more  are  lamed  in  many  of  the  acts  of 
chewing  food. 

In  Nortliwestern  University  Dental  School  we  have  occupied 
an  hour  or  more  during  each  year,  for  a  number  of  years,  in 
demonstrating  the  strength  of  the  bite,  by  asking  members  of 
the  class  to  make  trial  bites  on  a  gnathodynamometer.  (See 
Figure  102.)  In  these  trials,  we  find  men  in  every  class  who  can 
register  three  hundred  pounds,  and  some  of  them  appear  to  very 
easily  register  from  three  hundred  and  twenty-five  to  three 
hundred  and  fifty  pounds. 

The  apical  group.  The  fibers  of  this  group  spread  aroimd 
the  immediate  apex  of  the  root,  standing  out  fan-like  from  every 
part  and  passing  across  to  be  inserted  into  the  bone.  These 
fibers  are  usually  gathered  into  very  definite  bundles,  and  while 
the  fan-like  arrangement  is  correct,  as  a  general  description,  in 
many  cases  these  bundles  diverge  from  what  would  be  a  true 
fan-like  arrangement  to  one  side  or  to  the  other,  producing  a 
veiy  considerable  irregularity  in  the  crossing  of  the  bundles  one 
over  the  other  to  reach  the  bone.  As  we  approach  this  fan-like 
arrangement  of  fibers  around  the  apex  of  the  root,  we  find  the 
oblique  fibers  changing  their  direction  and  running  more  and 
more  directly  across  the  cementum  to  the  bone  until  they  meet 
the  fan-like  arrangement  of  the  apical  fibers.  (See  Figures  96 
and  101.) 

In  this  position,  we  have  in  effect  an  apical  horizontal  band 
of  fibers  encircling  the  root,  made  up  of  those  oblique  fibers 
which  are  very  nearly  horizontal  and  a  considerable  number  of 
fibers  of  the  apical  group  which  pass  outward  horizontally  or 
nearly  so.  While  the  root  of  the  tooth  is  swung  in  its  socket  by 
the  oblique  fibers,  these  horizontal  fibers,  which  pass  across  in 
the  change  to  the  fan-like  fibers,  around  the  apex  of  the  root, 
seem  to  have  a  special  function  of  holding  the  apical  portion  of 
the  root  centrally  in  its  socket,  against  any  lateral  pressure 
that  may  be  brought  upon  the  tooth. 

The  bundle  formation  of  the  fan-liko  fibers,  surrounding  tlie 
apex  of  the  root,  gives  space  to  a  considerable  indefinite  connec- 
tive tissue,  which  is  the  seat  of  the  inflammatory  condition  in 
the  beginning  of  alveolar  abscess. 


40  special  dental  pathology. 

The  indefinite  connective  tissue. 

There  is  in  the  peridental  membrane,  mixed  through  among 
the  principal  fibers,  a  considerable  amount  of  indefinite  connec- 
tive tissue,  forming  fibers  which  usually  run  somewhat  nearly 
l)arallel  with  the  length  of  the  tooth,  and  yet  there  are  a  good 
many  exceptions  to  this  rule.  They  may  take  almost  any  course. 
These  are  attached  to  connective  tissue  cells  and  they  are  pro- 
cesses from  these  cells  rather  than  true  fibers.  This  connective 
tissue  is  largely  the  supporting  tissue  of  the  blood  vessels, 
nerves,  veins,  etc.,  which  pass  to  and  fro  in  the  peridental  mem- 
brane. It  fills  up  all  the  interstices  between  the  bundles  of  the 
l)rincipal  fibers.  This  tissue  often  disappears  almost  entirely  in 
old  subjects.     (See  Figures  103  and  104.) 

Blood  vessels. 

The  blood  vessels  are  usually  seen  as  coming  into  the  peri- 
dental membrane  in  the  apical  space,  and  splitting  up  there  and 
running  parallel  with  the  length  of  the  tooth  to  the  crest  of  the 
alveolus  around  the  tooth,  and  there  connecting  with  the  blood 
vessels  from  the  gums  and  the  gingivae.  These  blood  vessels 
break  up  into  more  or  less  arterial  and  capillary  groupings,  as 
they  pass  through  the  peridental  membrane.  The  number  of 
these  varies  greatly.  In  injecting  specimens  of  the  peridental 
membrane  of  animals,  we  will  often  find  entering  the  apical  space 
an  artery  which  breaks  up  into  from  four  to  six  smaller  arteries, 
and  in  one  case  I  obsei'ved  eight  branches,  each  taking  its  way 
along  the  side  of  the  root.  Generally,  however,  there  are  fewer 
branches  given  off  in  the  apical  space,  and  as  they  take  their  way 
into  the  body  of  the  peridental  membrane,  they  separate  into  a 
number  of  smaller  branches.  It  is  sometimes  difficult  to  say 
whether  the  blood  vessels  enter  the  apical  space  or  terminate  at 
the  apical  space,  because  they  appear  to  also  enter  over  the  crest 
of  the  alveolar  process.  Blood  vessels  also  enter  and  pass  out 
from  the  peridental  membrane  all  about  the  body  of  the  root 
through  the  alveolar  process  in  quite  plentiful  numbers,  each 
passing  through  the  Haversian  canals  into  the  bone  and  splitting 
up,  more  or  less,  while  passing  through  the  bone,  giving  the  bone 
of  the  alveolar  process  a  veiy  rich  supply  of  blood,  as  well  as  a 
rich  collateral  circulation  for  the  peridental  membrane.  (See 
Figures  98,  104  and  109.) 

Nerves. 

The  nerves  of  the  peridental  membrane  follow  the  same 
course  as  the  blood  supply,  and  usually  these  lie  in  close  associa- 


THE    PERIDENTAL    MEMBRANE.  41 

tion  with  the  blood  vessels  which  pass  through  the  membrane 
longitudinally.  These  also  pass  through  the  Haversian  canals. 
A  tooth  does  not  lose  its  blood  supply,  nor  its  nerve  supply,  if 
the  whole  of  the  gingivae  is  cut  away  to  the  crest  of  its  alveolar 
process,  nor  if  the  whole  of  the  apical  space  is  cleared  of  tissue 
at  the  same  time.  The  collateral  circulation  through  the  bone 
itself  is  always  sufficient  to  maintain  its  vitality,  and  the  nerve 
supply  similarly  received  is  sufficient  to  maintain  its  sensations. 
The  sense  of  touch  will  remain  unimpaired,  and  the  sense  of  pain, 
in  cases  of  inflammation  of  the  membrane,  will  be  the  same  as  if 
the  peridental  membrane  were  perfect  in  all  of  its  parts. 

It  is  in  this  body  that  the  sense  of  touch  of  the  tooth  resides, 
the  slightest  touch  being  registered  as  such  on  the  sensorium. 
It  will  be  seen  then,  that  while  the  peridental  membrane  is  the 
organ  of  touch  for  the  root,  this  sense  of  touch  is  not  disturbed 
by  the  cutting  away  of  the  tissues  from  the  gingival  end  of  the 
membrane,  or  the  cutting  away  of  the  tissues  from  the  apical  end 
of  the  root,  or  by  cutting  away  both  at  once.  The  membrane  is 
found  to  retain  its  sensory  functions  both  as  to  pain  and  touch, 
through  all  this  mutilation.  The  peridental  membrane,  as  the 
true  organ  of  touch  of  the  tooth,  retains  this  sense  as  long  as 
there  is  any  of  the  peridental  membrane  attached  to  the  bone 
and  to  the  tooth. 

Osteoblasts. 

The  osteoblasts  of  the  peridental  membrane  are  in  no  wise 
different  from  the  osteoblasts  of  other  bone  regions  in  the  body. 
They  lie  upon  the  bone  of  the  inner  surface  of  the  alveolar  pro- 
cess the  same  as  upon  the  surface  of  other  bone.  They  almost 
completely  line  that  surface  of  the  bone  next  to  the  peridental 
membrane,  leaving  only  room  for  the  attachment  of  the  fibers 
of  the  peridental  membrane,  which  pass  between  them.  (See 
Figures  105,  106  and  107.)  Whenever  the  fibers  of  the  peri- 
dental membrane  lose  their  attachment  to  the  bone,  whether  it  be 
by  absorption  of  the  bone  or  otherwise,  these  cells  build  on  more 
bone  about  the  fibers  and  the  fiber  ends  calcify  with  this  bone 
and  are  thus  reattached  to  the  bony  wall.  This  function  occurs 
in  any  case  where  the  tooth  is  moved  because  of  the  extraction 
of  a  neighboring  tooth,  or  because  of  the  gross  movement  of  the 
tooth  in  the  jaw.  All  of  these  movements  call  for  al)sorption 
of  bone  from  one  side  of  the  root  to  give  way  for  the  movement, 
and  the  fibers  are  loosened  for  the  time  and  then  again  connected 
in  the  way  mentioned  above.     Sections  through  the  bone  show 


42  SPECIAL   DENTAL    TATHOLOGY. 

that  during  these  movements  the  fi])ers  are  loosened  in  patches 
here  and  there,  so  that  the  tooth  does  not  become  loose  by  any 
wholesale  detachment  of  the  fibers.  This  is  a  function  that  is 
shown  in  many  ways  by  the  movements  of  the  teeth  and  should 
be  recognized  by  the  dentist. 

Cementoblasts. 

The  cementoblasts  lie  upon  the  cementum  of  the  tooth  as 
thickly  as  the  osteoblasts  upon  the  bony  wall  of  the  socket  and 
perform  the  same  function  for  the  cementum  as  the  osteoblasts 
perform  for  bone.  They  are  instrumental  in  the  laying  down  of 
the  calcium  salts  in  the  building  of  cementum,  and  certain  of 
their  number  are  left  in  the  cementum  as  living  cells,  which  we 
call  cement  corpuscles,  the  same  as  osteoblasts  are  left  in  the 
bone  as  bone  corpuscles.     (See  Figures  108,  109,  110  and  111.) 

While  all  of  this  is  true  in  a  general  sense,  there  is  the  differ- 
ence already  mentioned  that  the  bone  has  in  itself  the  function 
of  repair  of  absorptions,  because  it  is  furnished  with  a  circula- 
tion of  red  blood,  which  penetrates  in  its  influence  to  eveiy  part 
of  the  bone  tissue,  while  the  cementum  has  no  blood  vascular 
system  and  has  no  power  of  self -repair.  So  far  as  has  ever  been 
demonstrated,  it  receives  no  sustenance  whatever  through  the 
dentin.  All  such  repairs  and  all  the  laying  down  of  the  new 
cementum  is  done  by  the  cementoblasts  of  the  peridental  mem- 
])rane.  Sometimes  these  absorptions  of  cementum  cut  away  its 
entire  thickness,  and  even  cut  into  the  dentin  to  various  depths. 
^Vherever  we  find  these  repaired,  which  we  do  frequently,  we 
find  that  the  whole  of  the  repair  is  made  by  cementum  which  has 
been  laid  down  by  the  peridental  membrane.  (See  Figures  66 
to  74.)  Such  repairs  are  made  only  under  conditions  of  com- 
plete asepsis.  Tn  cases  in  which  the  peridental  membrane  has 
been  stripped  from  the  cementum,  and  the  part  has  become 
infected  and  pus  soaked,  no  reattachment  whatever  may  be  made 
to  it  by  living  tissue.  It  is  a  dead  tissue.  This  is  not  a  new 
thought,  but  a  very  old  one.  Lister,  in  one  of  his  articles  in 
1867,  which  was  before  the  firm  establishment  of  the  influence  of 
micro-organisms  in  the  production  of  disease,  called  attention  to 
the  fact  "that  the  mere  contact  of  a  foreign  body  does  not  of 
itself  stimulate  gramdations  to  suppurate;  ivhereas  the  pres- 
ence of  decomposing  organic  matter  does."  He  states  that  a 
piece  of  dead  bone  "free  from  decomposition"  not  only  fails  to 
cause  suppuration  of  the  surrounding  tissue,  but  may  be 
absorbed;  while  pus-soaked  dead  bone  alwaj^s  produces  suppu- 


THE    PERIDENTAL    MEMBRANE.  43 

ration.  This  quotation  is  given  in  full  in  this  book  in  the  con- 
sideration of  the  condition  of  the  cementiun  in  chronic  alveolar 
abscess. 

This  quotation  shows  explicitly  that  the  failure  of  attach- 
ment to  bone  that  was  dead  and  pus-soaked  was  well  known 
long  ago,  and  also  the  fact  that  a  clean  piece  of  bone  planted 
in  the  tissue  might  be  absorbed,  was  at  the  same  time  per- 
fectly known.  The  one  of  these  was  as  completely  dead  as  the 
other,  but  it  was  the  previous  saturation  of  the  one  by  the 
products  of  suppuration  which  prevented  it  from  being  absorbed 
and  caused  it  to  keep  up  the  pus  formation ;  while  the  otlier, 
which  was  not  infected,  was  absorbed  by  the  tissue.  So  we  find 
the  fact  to  be  with  regard  to  cementum.  When  the  tissues  have 
lost  their  attachment  to  the  cementum,  because  of  pus  forma- 
tion, and  the  cementum  has  absorbed  this  pus  into  its  own  tissue, 
no  attachment  of  living  tissue  can  be  made  to  it,  as  has  been 
mentioned. 

Examination  of  the  soft  tissue  overlying  an  area  of  such 
detachment  reveals  the  additional  fact  that  these  specialized 
cells,  the  cementoblasts,  the  function  of  which  is  to  build  cemen- 
tum, have  disappeared,  evidently  having  been  destroyed  by  the 
suppurative  process  which  caused  the  detachment.  As  will  be 
shown  later,  the  principal  fibers  of  the  peridental  membrane, 
which  were  attached  to  the  cementum  over  such  an  area,  will 
also  have  disappeared,  together  with  the  corresponding  portion 
of  the  bone  of  the  alveolar  process  to  which  they  were  inserted. 
We,  therefore,  have  not  only  those  conditions  which  make  a 
reattachment  impossible,  but  the  cells  which  would  under  favor- 
able conditions  make  such  an  attachment,  have  disappeared,  as 
have  also  the  fibers  which  would  be  attached. 

These  are  among  the  most  important  facts  in  dental  pathol- 
ogy and,  unfortunately,  have  not  been  heretofore  recognized  by 
many  dentists. 

Epithelium. 

Among  the  tissues  of  the  peridental  membrane  there  is  a 
plentiful  distribution  of  epithelial  cells.  These  lie  for  the  most 
part  close  to  the  cementum  but  never  touch  it.  They  are  mingled 
among  the  principal  fibers,  generally  in  the  form  of  strings, 
sometimes  clubbing  together  so  as  to  l)o  several  cells  thick,  but 
often  in  strings  of  single  cells  touching  each  other.  These  occa- 
sionally form  loops  which  extend  outward  into  the  substance  of 
the  membrane  for  one-hnlf  its  tliicknoss,  or  more,  ;nid  then  dip 


44  SPECIAL   DENTAL   PATHOLOGY. 

back  again  to  a  position  near  the  cementiim.  These  cells  are 
found  everywhere  around  the  root  of  the  tooth,  but  in  general 
the  strings  are  so  disposed  as  to  run  lengthwise  of  the  root. 
(See  Figures  112  to  116.) 

I  was  very  much  puzzled  when  I  first  observed  these  cells. 
They  had  the  appearance  of  epithelium  and  stained  like  epithe- 
lium, but  I  could  not  conceive  at  the  time  the  possibility  of 
epithelial  cells  growing  in  such  a  position.  These  cells  were 
discovered  during  my  investigation  of  the  periosteum  and  peri- 
dental membrane,  and  in  writing  on  this  subject  in  1886-7,  I 
called  these  strings  of  cells  lymphatics.  I  later  realized  that 
they  really  were  epithelial  cells,  and  corrected  the  error  in 
naming  them.  I  know  of  no  other  occurrence  in  the  body,  of 
epithelium  among  the  connective  tissues  in  any  similar  form. 
In  fact,  the  whole  appearance  of  the  cellular  forms  seems  to  be 
out  of  place  and  accidental,  and  yet  they  are  found  in  all  the 
animals  of  the  higher  type,  as  well  as  in  man,  and  tlierefore  can 
not  be  regarded  as  accidental.  They  belong  to  the  tissues  of  the 
peridental  membrane,  but  their  function  has  been  a  question  for 
many  years. 

It  has  been  claimed  by  some  recent  writers  that  these  strings 
of  epithelial  cells  are  the  remains  of  the  breaking  up  of  the 
enamel  organ ;  the  cells  floating  away  and  taking  these  irregular 
forms.  To  my  mind  this  could  not  be.  I  have  followed  the 
breaking  up  of  the  cells  of  the  enamel  organ.  I  have  seen  them 
float  away  into  the  tissues  in  groups  forming  epithelial  pearls, 
some  large  and  some  very  small.  I  have  followed  them  from 
one  age  of  an  animal  to  another  age,  and  as  I  have  thus  followed 
them  I  have  found  that  they  were  absorbed  and  disappeared 
completely.  These  cells  seem  to  have  nothing  whatever  in  com- 
mon with  the  epithelial  cells  scattered  in  strings  in  the  peridental 
membrane.  They  are  not  like  them.  They  do  not  seem  to  be  of 
the  same  quality  at  all. 

Recent  investigations  of  these  cells  by  German  histologists 
have  been  carefully  reviewed  by  Dr.  Th.  Dependorf,*  and  his 
review  has  been  translated  and  printed  in  the  Northwestern 
Dental  Journal. f  Some  of  the  writers  seem  to  have  done  close 
microscopic  work,  and  while  they  differ  on  many  questions 
regarding  these  groups  of  cells,  there  is  one  upon  which  there  is 

*  Ziir  Pathogenese  der  Zahnwurzelzystem.  Deutsche  Monatsschrift  fiir  Zahnheil- 
kundo,  1912,  p.  809. 

•{•Dr.  Anna  A.  Opperniann,  Northwestern  Dental  Journal,  Vol.  X,  p.  73;  Vol. 
XI,  p.  9. 


Fm.   r.). 


Fig     75       Two    fields    of    c-cMncntun.    showing    ponetratiug_  fibers:      ct     Granular 
layer  of  Tomes,     c,  Cementum  not  slunvino   (ibcrs.  K,  Penetrating  fibers.     Noyes. 


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Fig.  76. 


Fig.  77. 


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Fig.  78. 


Fig.  76.  Section  of  cemciitum  of  pig  cut  horizontal  to  and  near  tiic  surface  of 
the  root  of  the  tooth  siiowiiig  cross  sections  of  the  inchuled  libers,  b.  Thin  margin  of 
section,  from  wliich  the  fibers  liave  fallen  out  of  their  alveoli,  c,  A  little  thicker 
portion  in  which  the  fibers  remain.  It  will  be  noticed  that  from  shrinkage  the  fiber 
is  a  little  small  for  its  alveolus,  so  that  it  is  slightly  separated  from  one  side,  a, 
Cement  corpuscles. 

Fig.  77.  Longitudinal  sfction  of  the  cementuui  of  a  pig,  showing  the  included 
fibers  of  the  peridental  membrane,  e,  Margin  of  cementum  showing  fibers  passing 
from  the  cementum  to  the  peridental  membrane,  and  the  layer  of  cementoblasts  with 
other  cells  in  the  neighborhood,  f.  Epithelial  cells,  d,  d,  Fibers  protruding  from 
broken  margin  of  section,     a.  Dentin,     b.  Junction  of  dentin  and  cementum. 

Fig.  78.  Cementum  of  pig  from  the  dried  section,  a,  Dentin,  b,  Lacuna?  of 
cementum  with  canals  anastomosing  with  each  other,  c.  Imperfectly  calcified  fibers. 
It  will  be  noticed  that  a  few  of  the  dentinal  tubes  pass  through  into  the  cementum. 


Fig.  79. 


F\r,.  sil. 


Fig  79.  A  transverse  section  of  a  root  extracted  from  a  young  person.  The 
cementum  is  thin,  but  is  thicker  in  the  groves  on  the  proximal  sides,     ^oycs 

Fig.  80.  A  transverse  section  of  a  root  fro,n  an  old  person.  ^^rZl  L'Z' 
ried  a  crown  for  many  years.     The  section  was  cracl<ed  and  one  edge  broken,    ^oycs. 


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Fig.  81. 


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iimwimm. 


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Fig.  82. 


Fig.  81.  Hypertrophy  of  the  cemcntum  on  the  side  of  the  root  of  a  lower 
molar  near  the  gingival  line  of  the  tooth.  From  a  longitudinal  section,  man.  a, 
Dentin,  b,  Cementnm.  c,  Fibers  of  peridental  membrane.  From  b  to  c  the  cementum 
is  normal,  and  the  incremental  lines  fairly  regular,  but  at  d,  one  of  the  lamellae  is 
greatly  thickened.  .At  c,  tliis  lamella  is  seen  to  be  about  equal  in  thickness  with  the 
others. 

The  next  two  lamella;  are  thin  over  the  greatest  prominence,  but  one  is  much 
thickened  at  g  and  both  at  h.  These  latter  seem  to  partially  fill  the  valleys  which 
were  occasioned  by  the  first  irregular  growth. 

Fig.  82.  Hypertrophy  from  ^oot  of  cuspid,  man,  in  which  the  irregularity  is 
confined  to  the  first  lamella,  a,  Dentin,  b.  Thickened  first  lamella,  c.  Subsequent 
lamella-,  which  are  seen  to  be  fairly  regular. 


Fig.  83. 


Fig.  84. 


Fig.  8.5. 


Fig.  8G. 


Fig.  87, 


Fig.  83.  Apex  of  root  of  an  upper  first  bicuspid  tooili  with  irrcguiiirly  developed 
eementum.  a,  a,  Dentin,  b,  b,  Pulp  canals.  The  lamella  of  cenientuni  are  marked 
1,  2,  3,  etc.     d,  d,  d,  Absorption  areas  that  have  been  refilled  with  cenientuni. 

It  will  be  seen  that  the  apices  of  the  roots  were  ori^niially  separate,  but  became 
fused  with  the  deposit  of  the  second  lamella  of  cenientum,  and  that  in  this  the 
irregular  growth  began  and  was  most  pronounced.  It  has  continued  through  the 
subsequent  lamelhe,  but  in  less  degree.  Tt  will  also  be  noticed  that  the  absorption 
areas,  d,  d,  d,  have  proceeded  from  certain  lamella'.  Between  the  roots  this  has 
broken  through  the  first  lamella  and  penetrated  tlie  dentin,  and  has  been  filled  with 
the  deposit  of  a  second  lamella.  Other  of  the  absorptions  have  jiroceeded  from 
lamellsp,  which  can  be  readily  made  out.  The  small  iioints.  e,  seem  to  have  been 
filled  with  the  deposit  of  the  last  layer  of  the  cenientuin.  wliilc  oUkm-s  have  one,  two 
or  more  layers  covering  them. 

Figs.  84,  8.5,  86  and  87.  Teeth  with  extensive  hypercemeiitosis.  Sp(>ciiiiens  from 
Northwestern  University  Dental  Museum.  Tooth  shown  in  Fig.  84  jiresented  by 
Dr.  T.  A.  Black,  Galveston,  Texas.  Teeth  shown  in  Figures  sn  and  8()  jiresented  l)y 
Dr.  Amy  Bowman,  T^os  Angeles,  California. 


Fig.  88. 


Fig.  89. 


Fig.  90. 


Fig.  91. 


Fig.  92. 


Fics.  88,  89  AND  90.  Teeth  with  roots  fused  by  the  coalescence  of  cementum. 
Specimens  from  Northwestern  University  Dental  Museum. 

FIG.S  91  AND  92  Teeth  with  roots  fused  by  the  coalescence  of  cementum. 
Specimens  from  Northwestern  University  Dental  Museum.  Teeth  shown  an  Figure  92 
presented  by  Dr.  A.  S.  Cheeseman.  .Toliet,  Illinois. 


n^f  at 


FlO.  93. 


Fig.  93.  Longitudinal  bucco-Iingiial  section  through  root  of  tooth  and  gingival 
portion  of  investing  tissue  showing  fibers  of  the  peridental  membrane.  E.  Epithelium. 
D,  Dentin,  c,  Cementum.  s,  Subgingival  space.  F,  Free  gingiva?  group  of  fibers. 
A,  Alveolar  crest  group  of  fibers,  ii,  Horizontal  group  of  fibers,  b,  Bone  of  alveolar 
process.     Noyes. 


i<'^  */  pit 


Fig.  94. 


Fig.  9.5. 


Fig.  ,)4.  Longritn.linal  .section,  slightly  obliquo.  through  root  and  noridental 
membrane,  shoAving  fibers  of  the  peridental  membrane,  e,  Epithelium,  d,  Dentin. 
c,  Lementum.  s,  Subgingival  space,  f,  Free  gingiva-  group  of  fibers,  a,  Alveolar 
crest  group  of  fibers,  h,  Horizontal  group  of  fibers,  o.  o.  Oblique  group  of  fibers 
B,  Hone  of  alveolar  process. 

Fig.  9.5.     A  higher  magnification  of  a  part  of  Figure  94. 


THE    PERIDENTAL.    MEMBRANE.  45 

general  agreement,  viz.,  that  these  strings  of  epithelial  cells  mul- 
tiply in  the  peridental  membrane,  break  up,  form  sheets  of  cells 
which  surround  certain  areas  of  infection,  and  cut  them  off  by 
encysting  them.  The  activities  of  these  cells  will  be  more  fully 
considered  under  the  subject  of  cyst  formation. 

Physiological  Powers  of  the  Peridental  Membrane  and 
Cementum,  as  Shown  by  Planted  Teeth, 

ILLUSTRATIONS:    FIGURES  117-119. 

The  physiological  powers  of  the  several  elements  which  com- 
pose the  peridental  membrane,  their  correlation  to  the  cementum 
in  minute  anatomy  and  in  function,  and  especially  their  power 
and  lack  of  power  to  repair  themselves  and  renew  their  physio- 
logical connections  with  their  related  tissues  when  injured  by 
disease  or  accident,  are  of  much  more  than  usual  importance.. 
Dentists  have  been  very  slow  in  gaining  an  understanding  of 
the  peridental  membranes  and  their  relations  to  the  tissues  with 
which  they  are  connected,  because  they  have  made  so  little  prac- 
tical study  of  these  tissues.  Really  they  have  had  but  little 
opportunity  to  know  this  subject,  since  it  has  been  taught  very 
superficially,  if  at  all,  in  dental  schools.  In  efforts  made  by  the 
general  profession  to  study  the  diseases  of  the  peridental  mem- 
brane and  cementum,  they  have  disregarded  the  powers  of  these 
tissues,  and  therefore  have  failed  to  gain  the  most  beneficial 
infonnation. 

The  planting  op  teeth. 

The  famous  surgeon,  John  Hunter,  whose  professional 
activities  were  around  1750-90,  and  who  seems  to  have  given 
unusual  attention  to  the  teeth,  did  quite  a  little  in  transplanting 
and  implanting  teeth.  This  operation  seems  to  have  become 
quite  popular  in  Europe  during  the  latter  part  of  the  centuiy, 
but  soon  died  away  and  was  lost  to  sight.  It  was  not,  however, 
original  with  Hunter.  Guerini  gives  credit  to  Amboise  Pare 
for  having  first  performed  and  described  this  operation.  It  had 
been  known  and  practiced  and  had  passed  out  of  use  several 
times  before  his  day.  Even  after  the  beginning  of  the  last 
century,  the  transplantation  of  human  teeth  was  practiced  in 
France,  and  perhaps  elsewhere.  There  was  develo]ied  a  ]irac- 
tice  of  transplanting  directly  from  one  human  mouth  to  another. 
The  dentist,  being  applied  to  for  a  new  tooth,  would,  after  deter- 
mining what  was  needed,  find  some  person  who  was  willing  to 

*6 


46  SPECIAL   DENTAL    PATHOLOGY. 

sell  a  similar  tooth  for  a  price.  Or  a  good  careful  lady  would 
bring  with  her  a  servant  girl  who  would  sell  one  of  her  teeth. 
Then  the  carious  tooth  would  be  extracted  from  the  patient  and 
thrown  aside.  The  similar  tooth  was  then  removed  from  the 
mouth  of  the  person  furnishing  the  tooth  for  replacement.  The 
tooth  was  at  once  transferred  to  the  alveolus,  from  which  the 
carious  tooth  had  been  removed.     (See  Figure  117.) 

The  practice  seems  not  to  have  lived  very  long,  nor  to  have 
become  very  general.  No  careful  records  of  operations  of  this 
character  seem  to  have  been  kept.  Neither  can  we  suppose  from 
the  writings  which  have  come  down  to  us  that  the  powers  of 
repair  in  the  tissues  involved  were  given  careful  study.  I  have 
been  over  most  of  the  old  writings  in  the  English,  German  and 
French  languages,  and  I  do  not  now  remember  of  a  single  case 
in  which  there  was  an  effort  to  make  a  close  study  of  this  mem- 
brane, or  of  its  physiological  powers. 

During  the  century  just  passed  there  were  occasional 
revivals  of  the  practice  of  planting  teeth  in  the  sockets  from 
which  teeth  had  been  extracted,  often  using  old  dried  teeth  for 
the  purpose.  These  efforts  were  usually  individual  in  character 
in  that  they  were  confined  to  a  few  persons. 

In  more  recent  years,  the  practice  has  been  revived  on  the 
assumption  that  by  the  use  of  antiseptics,  lasting  operations 
both  in  transplantation  and  implantation  might  be  made.  A 
good  many  operations  were  made  and  attracted  considerable 
attention  at  dental  society  meetings,  but  as  time  wore  on  it  was 
found  that  these  operations  failed  after  a  few  years,  the  same  as 
others  had  done. 

However,  with  the  more  careful  following  of  cases  which  had 
become  possible,  the  advisability  of  this  operation  in  individual 
cases  was  better  studied.  The  result  has  been  that  a  few  opera- 
tors have  made  the  most  possible  of  its  use  in  carefully  selected 
cases.  So  far  as  I  have  knowledge,  transplantations  from  per- 
son to  person  have  not  been  made  in  recent  years,  except  by  a 
very  few  practitioners. 

During  the  revival  of  this  procedure,  a  nomenclature  became 
fairly  established  representing  the  different  classes  of  planting 
operations. 

Replantation  is  used  when  teeth  are  extracted  purposely  or 
by  accident,  and  replaced  in  their  own  sockets. 

Trayisplantation  is  used  when  a  stranger  tooth  is  placed  in 
the  socket  of  a  tooth  just  removed. 


•PERIDENTAL    MEMBRANE    PHYSICAL    POWERS.  47 

Implantation  is  used  when  the  teeth  have  been  removed  at 
some  former  time  and  a  new  socket  is  cut  in  the  residual  alveolar 
process,  or  ridge,  and  a  stranger  tooth  planted  in  it. 

Taking  the  mass  of  evidence  afforded  by  the  history  of 
planted  teeth,  there  has  been  every  degree  of  success  and  failure 
which  seems  possible.  A  study  of  these  successes  and  failures 
illustrates  the  physiological  powers  of  the  tissues  to  make 
repairs  when  the  peridental  membrane  and  the  cementum  have 
been  separated  from  any  cause,  or  when  the  wound  made  by  the 
extraction  has  healed  and  all  vestige  of  a  peridental  membrane 
has  disappeared.  The  lesson  thus  learned  of  the  powers  of  the 
tissues  under  such  conditions  is  the  all  important  thing  for  which 
this  recitation  is  made. 

A  considerable  number  of  cases  were  failures  from  the  start. 
Suppuration  occurred  in  the  socket  about  the  tooth,  and  it  had 
to  be  removed  within  a  few  days  or  weeks.  It  seems  to  have 
been  suflSciently  demonstrated  that  no  attachment  would  be  made 
in  areas  of  suppuration.  Often  there  will  be  some  suppuration 
about  the  gingival  margin  of  otherwise  successful  cases.  My 
personal  observation  is  that  the  soft  tissue  never  becomes 
attached  over  such  areas,  and  the  gum  quickly  shrinks  away, 
leaving  some  portion  of  the  root  bare.  In  other  cases  the  soft 
tissues  heal  about  the  teeth,  and  they  become  tight  or  fixed 
immovably  in  the  sockets.  These  teeth,  which  seem  to  present 
the  most  perfect  condition,  are  usually  lost  within  one,  two  or 
three  years,  by  absorption  of  the  root.  (See  Figures  118  and 
119.)  If  such  a  tooth  remains  useful  for  five  years,  it  is 
regarded  as  a  first-class  result. 

No  HISTO-PATHOLOGICAL  STUDIES  OF  PLANTED  TEETH.       Nothlug 

is  yet  very  certainly  known  of  the  histo-pathology  in  these  cases. 
A  number  of  the  remains  of  absorbed  roots  have  been  cut  for 
microscopic  study,  but  these  have  given  little  information.  I  do 
not  now  remember  of  any  case  in  which  the  root  of  the  tooth, 
with  its  soft  tissue  and  bony  investments  as  it  was  in  tlie  ,iaw, 
has  been  prepared  for  the  microscope  and  studied  ])y  a  compe- 
tent observer.  Therefore,  we  are  yet  without  definite  informa- 
tion from  the  histological  standpoint  as  to  what  occurs  either  as 
the  tooth  becomes  tight,  the  tissue  by  which  it  is  held,  or  the 
process  of  absorption  l^y  which  it  is  removed. 

In  reciting  this  history  T  have  had  no  intention  of  describing 
in  detail  the  several  operations  of  planting  teeth.  My  purpose 
has  been  to  illustrate  a  principle  in  the  coordinate  physiology 
controlling  the  relations  of  the  cementum  and  the  peridental 


48  SPECIAL   DENTAL   PATHOLOGY. 

membranes.  Particular  note  should  be  made  of  the  fact  that 
in  some  of  these  operations,  old  dried  teeth,  which  had  been  out 
of  the  mouth  a  long  time,  have  been  selected  for  planting.  These 
seem  to  have  done  about  as  well  as  comparatively  fresh  teeth, 
but  not  so  well  as  teeth  which  were  removed  or  displaced  by 
accident,  and  in  which  the  same  tooth  was  immediately  replaced 
into  its  own  socket. 

It  has  been  said  that  John  Hunter,  whom  I  have  mentioned, 
had  at  one  time  several  roosters  about  his  yard  with  two  or  more 
human  teeth  planted  successfully  in  their  combs.  Also  that  an 
enthusiastic  Frenchman  succeeded  in  planting  a  human  tooth  in 
the  forehead  of  a  rat,  and  it  became  firmly  fixed  to  the  skull. 
I  will  not  vouch  for  the  correctness  of  either  of  these  stories, 
but  from  that  which  I  have  myself  seen,  I  believe  both  are 
possible. 

Chemotaxis.  The  meaning  of  the  above  line  of  facts  is  that 
there  exists  between  the  soft  tissue  cells,  or  some  of  them,  and 
the  cementum  covering  the  roots  of  the  teeth,  or  even  the  dentin 
itself,  a  positive  cliemotaxis  which  causes  the  soft  tissue  cells  to 
seek,  or  to  approach,  the  cementum,  to  develop  in  contact  with  it 
and  attempt  to  make  an  attachment. 

The  principle  in  nature  expressed  by  this  word  chemotaxis 
(Chemo — Chemistry,  and  taxis — orderly,  or  in  an  orderly  way) 
has  assumed  great  importance  within  recent  years  in  physiology, 
pathology,  bacteriology  and  immunity  from,  or  susceptibility  to, 
infections  and  infectious  diseases.  It  serves  to  explain  many 
things  which  previously  seemed  incomprehensible. 

The  Standard  Dictionary  gives  the  following  definition: 
' '  Chemotaxis :  The  property  which  certain  living  motil  cells 
possess  of  approaching  (positive  chemotaxis)  or  moving  away 
from  (negative  cliemotaxis)  chemical  substances  of  various 
kinds.  Chemotaxis  seems  to  play  an  important  part  in  some 
phases  of  inflammation.  Thus  it  appears  to  be,  in  part  at  least, 
through  the  incitement  of  chemotaxis  by  the  chemical  substances 
which  they  contain  or  eliminate,  that  bacteria  act  in  producing 
suppuration." 

Stedman's  Medical  Dictionary  gives  the  following  defini- 
tion :  ' '  Chemotaxis :  Reaction  of  living  protoplasm  to  a  chemical 
stimulus  wiiereby  the  cells  are  attracted  (positive  chemotaxis) 
or  repelled  (negative  chemotaxis)  by  acids,  alkalies  or  other 
bodies  exhibiting  chemical  properties." 

It  is  through  the  principle  expressed  in  these  definitions  that 
many  of  the  physiological  and  pathological  reactions  occurring 


PERIDENTAL   MEMBEANE    PHYSICAL   POWERS.  49 

between  tissues  of  different  kinds  are  brought  about.  It  seems 
also  that  it  is  a  principle  which  is  often  active  in  infective  inva- 
sions of  micro-organisms,  or  in  preventing  such  invasions,  and 
thus  bringing  about  conditions  of  susceptibility  or  of  immunity. 

On  the  basis  of  a  positive  chemotaxis,  we  may  explain  a 
fact  that  is  sufficiently  apparent  in  the  line  of  experiment  recited. 
AVhen  a  tooth,  which  has  been  extracted  for  some  time,  is  planted 
in  the  tissues  of  the  jaws,  whether  in  a  previously  existing  socket 
of  a  tooth  or  a  socket  cut  for  it,  under  conditions  fairly  favorable 
to  the  healthful  action  of  the  soft  tissue  elements  of  the  neigh- 
borhood, there  is  an  immediate  tendency  for  the  cellular  ele- 
ments, or  certain  of  them,  to  attach  themselves  to  the  root  of  the 
tooth  and  develop  there  into  fixed  tissue.  In  this  way  they  form 
an  attachment  to  cementum,  or  even  to  dentin.  A  growth  occurs 
that  we  may  suppose  endeavors  to  reform,  or  to  form  an  ordi- 
nary peridental  membrane.  It  is  more  probable  that  the  tissues 
act  much  in  the  same  way  in  which  open  wounds  heal  by  the 
formation  of  cicatricial  tissue. 

As  the  peridental  membrane  is  a  specialized  tissue,  having 
in  its  make-up  several  kinds  of  cellular  elements  and  of  fibers 
specially  arranged  for  the  performancec  of  its  special  functions, 
we  must  suppose,  from  the  uniform  disastrous  results  which 
follow  all  forms  of  planting  teeth,  that  at  least  some  parts  of 
these  have  failed,  if  indeed  there  is  any  definite  attempt  to 
reform  them.  Therefore  the  connection  is  physiologically  unsta- 
ble. For  this  reason  the  absorptive  process  begins  in  the  root 
and  continues  more  or  less  rapidly  until  the  tooth  is  cast  off. 

Attachment  or  planted  teeth  physiologically  unstable. 

The  absorption  of  the  root  is  the  universal  result  of  all  kinds 
of  planting  of  teeth  in  the  jaws.  The  history,  therefore,  shows 
conclusively  that  the  attachment  is  physiologically  unstable. 
It  shows  further,  that  positive  chemotaxis  is  changed  to  negative 
chemotaxis  whenever  the  root  of  the  tooth,  or  some  portion  of  it, 
has  been  exposed  to  suppuration  and  has  presumably  absorbed 
products  of  suppurative  decomposition.  If  we  comi)are  the  con- 
ditions of  the  peridental  membrane  and  the  cementum  in  cases  of 
replantation  and  in  cases  where  pockets  have  formed  beside  the 
roots  of  teeth,  we  find  the  conditions  so  similar  that  we  may  well 
regard  them  as  the  same.  With  the  suppuration  which  has 
occurred  and  the  loosening  of  the  soft  tissues,  we  must  suppose 
that  the  integrity  of  the  peridental  membrane,  as  such,  and  of  its 
special  elements  which  fit  it  for  the  performance  of  its  functions, 


50  SPECIAL    DENTAL   PATHOLOGY. 

have  been  destroyed,  and  that  the  tissue  in  its  place  is  ordinary 
gingival  or  gum  tissue,  which  has  been  modified  and  weakened 
by  repeated  inflammations  and  suppurations.  Over  against  this 
is  a  cementum  that  has  lost  its  positive  chemotactic  qualities  by 
having  absorbed  the  products  of  suppuration.  To  cap  the  climax 
of  disabilities  present  in  these  cases,  they  are  placed  in  a  field 
constantly  exposed  to  active  infective  elements,  and  are  con- 
stantly being  reinfected.  The  conditions  are  such  that  these 
reinfections  are  not  preventable. 

When  we  compare  the  above  with  a  fresh  wound  created  by 
forming  a  new  socket  in  the  residual  alveolar  process,  or  by 
clearing  a  socket  where  a  tooth  has  somewhat  recently  been 
extracted,  we  will  see  at  once  that  the  condition  of  the  tissue  in 
a  socket  so  prepared  for  the  reception  of  an  implantation  is  in 
better  condition  to  invite  an  adhesion  of  soft  tissue  than  in  any 
case  in  which  the  tissue  has  been  detached  by  an  infection  along- 
side a  root. 

Under  all  of  these  adverse  conditions,  how  shall  we  expect 
pockets  to  heal,  reattachment  of  the  soft  tissues  to  the  cementum 
to  occur,  and  permanent  cures  of  this  condition  to  be  made?  As  a 
matter  of  fact,  such  cures  do  not  occur,  nothwithstanding  the 
reports  of  successes. 

As  I  must  acknowledge  that  in  the  past  I  was  for  a  consid- 
erable time  deceived  by  the  appearance  of  betterment  which 
followed  treatment,  and  supposed  and  stated,  as  will  be  found  in 
the  article  I  prepared  for  the  American  System  of  Dentistry,  that 
actual  cures  occurred  under  these  conditions,  the  above  statement 
should  not  be  taken  as  offensive  by  any  one  now  in  practice. 

The  Alveolar  Processes. 

ILLUSTRATIONS:    FIGURES  120121. 

The  alveolar  process  is  the  projection  of  bone  which  grows 
up  around  the  roots  of  the  teeth,  and  forms  the  sockets  in  which 
the  roots  of  the  teeth  are  held  by  their  membranes. 

These  sockets  are  the  alveoli  of  the  teeth,  or  if  we  speak  in 
the  singular,  each  socket  is  the  alveolus  of  a  tooth.  The  word 
alveolus  means  a  hole.  The  alveolar  process  is  the  wall  of  bone 
around  the  hole.  This  is  not  a  separate  piece  of  bone  but  is  con- 
tinuous without  demarcation  with  the  bones  which  form  the 
maxillcT.  There  seems  to  have  been  no  rule  among  writers  on 
dental  subjects  as  to  the  use  of  the  singular  and  plural  forms, 
alveolar  process  and  alveolar  processes. 


THE    AL^T<:OLAE    PROCESSES.  51 

The  peridental  membrane,  as  united  to  the  cementum  on  the 
one  side  and  to  the  alveolar  wall  on  the  other,  connects  and  binds 
together  the  root  of  the  tooth  and  its  alveolar  process,  thus  hold- 
ing the  tooth  in  position.  (See  Figures  97  and  98.)  Really 
there  is  but  a  single  alveolar  process  in  each  jaw,  which  passes 
around  the  arch  in  a  single  bony  projection  in  which  there  are  the 
number  of  alveoli  for  the  accommodation  of  the  roots  of  the 
teeth.  In  most  cases  the  projection  of  the  alveolar  process  above 
the  body  of  the  bone  is  not  sufficient  to  accommodate  the  full 
length  of  the  roots  of  the  teeth,  and  the  alveoli  are  sunk  into  the 
body  of  the  bone  so  far  as  may  be  necessary. 

The  alveolar  process  does  not  quite  cover  the  gingival 
portion  of  the  cementum,  but  stops  about  two  millimeters  short 
of  the  gingival  line  of  the  tooth,  different  specimens  varying 
somewhat  from  this  measurement.  The  crest  of  the  alveolar 
process  is  therefore  always  lower  than  the  gingival  lines  of  the 
teeth. 

The  alveolae  processes  are  bone. 

The  alveolar  processes  are  bone,  pure  and  simple,  with  all 
of  the  endowments  of  the  bones  in  general.  Their  blood  supply 
is  richer  than  that  of  most  bones,  their  Haversian  canals  are 
larger,  and  the  amount  of  blood  passing  through  them  is  greater 
than  in  the  bones  in  general.  The  nerve  supply  is  also  richer. 
To  accommodate  this  very  rich  circulation,  the  alveolar  pro- 
cesses are  permeated  by  many  Haversian  canals  and  a  large 
number  of  these  pass  through  directly  or  indirectly  from  the  side 
of  the  mucous  membrane  to  the  side  of  the  peridental  membrane, 
or  the  reverse,  giving  to  the  peridental  membranes  a  rich  collat- 
eral circulation  through  the  alveolar  wall. 

Wherever  the  bone  constituting  the  alveolar  wall  is  con- 
siderably thickened,  it  has  a  fairly  solid  cortical,  or  surface  por- 
tion, toward  the  mucous  membrane  side,  and  a  thinner,  fairly 
solid  portion  on  the  side  next  to  the  peridental  membrane.  In 
the  central  portion  between  these  two,  the  bone  is  much  less  dense. 
Indeed,  wherever  there  is  thickness  enough  to  ]^ermit  it,  it 
becomes  cancellous  or  medullary.  It  is  divided  in  many  direc- 
tions with  thin  laminae  of  bone,  uniting  the  whole  together  in  a 
strong  mass,  in  which  the  interspaces  are  filled  with  connective 
tissue,  blood  vessels  and  nerves,  giving  it  a  physiological  activity 
closely  related  to  the  ordinary  connective  tissues. 

The  alveolar  process  rises  much  higher  above  the  true  form 
of  the  maxillary  l)ones  in  the  front  ])art  tlian  it  does  in  the  back 


52  SPECIAL.   DENTAL   PATHOLOGY. 

part  of  the  mouth.  It  is  therefore  higher  about  the  incisors  and 
cuspids  and  lowers  away  toward  the  back  part  of  the  mouth  until, 
in  the  lower  jaw  particularly,  the  alveoli  for  the  second  and  third 
molars  are  often  hollowed  out  in  the  body  of  the  bone.  Indeed 
in  many  cases  the  alveolar  walls  on  the  lingual  sides  of  these  teeth 
are  built  out  around  them  as  they  lie  one-half,  more  or  less,  out 
on  the  lingual  side  of  the  bone.  In  the  upper  jaw  a  much  more 
decisive  alveolar  ridge  is  maintained  even  to  the  third  molars,  but 
this  part  of  the  ridge  is  much  lower  than  in  front. 

Development  of  the  alveolar  processes. 

One  who  has  followed  carefully  the  development  of  the 
teeth  and  the  dental  arches  in  the  clinical  way,  together  with  the 
occlusion  of  the  teeth,  in  many  children,  and  the  malocclusions 
which  occur  among  them,  will  have  discovered  that  the  teeth 
are  not  made  to  fit  their  alveoli,  but  that  the  alveoli  are  made 
to  fit  the  teeth.  The  teeth,  during  the  development  of  the 
arches,  go  on  with  their  movements  as  the  bones  of  the  face  are 
growing  and  expanding  from  the  face  of  the  child  to  the  face 
of  the  adult.  The  teeth  are  assuming  the  adult  positions  by 
which  they  are  assisting  in  rounding  out  the  prominences  of  the 
adult  features.  During  this  time  the  alveolar  processes  are 
keeping  even  pace  with  the  movements  of  the  teeth.  As  the 
teeth  move  forward,  the  alveolar  walls  are  absorbed  here  and 
built  out  there,  to  accommodate  the  movement.  (See  Figures 
120  and  121.)  If  some  one  or  more  of  the  teeth  are  taking 
wrong  positions,  bringing  about  malocclusions,  they  are  not  lim- 
ited or  perceptibly  held  back  by  their  alveoli;  but  the  alveolar 
walls  will  be  changed  in  form  and  built  to  fit  the  teeth  in  the  mal- 
position. A  cuspid  tooth  that  is  crowded  forward  out  of  its 
normal  position,  for  instance,  has  the  walls  of  its  alveolus 
changed  to  accommodate  this  movement.  It  is  not  crowded  out 
of  its  alveolus.  It  does  not  lose  the  fitting  of  an  alveolar  wall 
around  it  because  the  tooth  has  taken  a  wrong  position.  This 
exhibits  in  i)art  the  related  physiological  factors  existing  between 
alveolar  processes  and  teeth  and  the  bones  of  the  face. 

All  of  this  goes  to  show  that  in  the  related  physiological 
factors  between  the  positions  of  the  teeth  in  the  arch  and  the 
formation  of  the  walls  of  their  alveoli,  the  teeth  are  accommo- 
dated by  the  growth  of  bone  about  them,  and  are  given  the  sup- 
port that  the  performance  of  their  functions  demands.  Even  if 
there  are  supernumerary  teeth,  not  usually  reckoned  with  as 
normal,  their  alveolar  process  is  built  about  them  in  any  position 


0      ''    % 


Pig.  96. 


Fig  96  Drawing  representing  a  longitudinal  section,  to  illustrate  the  fan- 
shaped  fibers.  It  is  almost  impossible  to  get  an  actual  section  through  the  tissues 
which  shows  the  arrangement,  on  account  of  the  interlacing  of  tlic  various  bundles  of 
fibers. 


Fig.  97. 


Fig.  97.  Transverse  section  of  the  peridental  membrane  in  the  occlusal  third 
of  the  alveolar  portion  (from  sheep),  m.  Muscle  fibers,  per.  Periosteum.  a1,  Bone 
of  the  alveolar  process.  Pd,  Peridental  membrane  fibers,  p,  Pulp.  D,  Dentin,  cm, 
Cementuni.     Noyes. 


Fig.  98. 


Fig.  98.  Cross  section  of  the  root  of  a  tomporary  incisor  with  the  pendentil 
membrane  and  alveolar  walls,  at  about  the  middle  of  the  lower  third  of  body  of  the 
peridental  meinbrane,  showing  the  direction  of  the  fibers  of  the  membrane,  and  the 
position  of  the  blood  vessels,  a,  The  dentin,  b,  Cementiiin.  c.  Pulp.  Its  blood 
vessels  are  shown,  d,  d,  Alveolar  wall,  septi  between  the  teeth,  e.  (-.Peridental 
membrane.  The  direction  and  arrangement  of  its  fibers  have  been  ("arefvdly  repre- 
sented; also  the  position  and  relative  size  of  its  blood  vessels,  f,  Thiu  portion  of 
the  anterior  alveolar  wall,     g,  Hypertrophy  of  the  cementum. 


(r'^-^^^-^'^-r^ 


FiQ.  99. 


^;^,j^^;j\v^^-^^^\^>^?^?J^^ 


Fro.  101. 


Fig.  99.  Fibers  of  the  peridental  iiienibrane  passing  from  the  cementiim  a,  to 
the  alveolar  wall  b.  The  section  is  from  tlie  root  of  a  first  molar  of  a  man  about 
seventy  years  old.  The  point  eliosen  for  tliis  illustration  includes  a  portion  of  a 
strong  band  of  solid  fibers  c,  which  pass  unbroken  from  the  eementum  to  the  bone. 
More  generally,  the  fibers,  after  emerging  from  the  eementum,  break  up  into  finer 
fibers  or  fasciculi,  as  at  d.     This  form  of  the  fibers  is  better  shown  in  Fig.  100. 

Fig.  100.  Fibers  emerging  from  the  eementum  and  breaking  up  into  fasciculi. 
From  the  peridental  membrane  of  a  molar  of  an  aged  person.  This  represents  the 
more  usual  form  of  the  principal  fibers,  as  seen  in  old  age  in  man.  They  pursue  a 
somewhat  wavy  course,  and  generally  the  identity  of  the  individual  fiber  is  lost. 
They  are  inserted  into  the  bone  in  compact  bundles  similar  to  those  of  the  eementum. 

Fig.  101.  A  group  of  fibers  emerging  from  the  eementum  near  the  apex  of  a  root 
and  radiating  fandike.  On  either  side,  the  principal  fibers  are  absent  for  a  little 
space,  which  is  filled  with  indifferent  tissue.  From  the  apical  space  of  a  bicuspid  of 
an  old  person. 


Fig.  102. 


Fig.  102.  The  gnathodynaniometcr,  about  tAvo-thirds  natural  size.  Face  view. 
c,  c,  The  rubber  pads  bitten 'upon  in  determininp:  the  ]>ressure  of  the  teeth,  d.  Scale 
of  pounds.  E.  Needle  Avhich  marks  tlie  pounds.  In  use  this  needle  riMiiaiiis  stntionary 
at  the  highest  point  reached  until  it  is  moved  by  the  iingers. 


Fig.  ]03. 


Tig.   104. 


Fig.  103.  Fibers  and  fil)rol)lastH  from  transversp  section  of  membrane:  F,  Fibers 
cut  transversely.     f1.  Fibers  cut  lonfrituilinally.  showing  fibroblasts.     Noye.t. 

Fig.  104.  Peridental  membrane  from  perpendifular  section  of  a  tooth  of  the 
pig,  stained  with  nucleus  tinting  stain,  a,  f'ementum.  li,  Bone,  c,  Blood  vessels 
cut  diagonally,  d.  Nerve  bundle,  e.  Epithelial  cells.  A  number  of  strings  and 
clusters  of  these  are  seen  near  the  cemer.tum.  The  principal  fibers  are  transparent, 
while  the  interfibrous  tissue  is  stained.  The  cellular  elements  appear  in  rows  between 
the  principal  fillers,  which  are  large  and  strong  near  the  bone,  ami  only  partially 
break  up  into  fascicidi  in  the  central  part  of  their  length. 


PdM 


rd  F. 


HE 


Fig.    U).-j 


Fig.  10.5.  Pcnotratirifr  fibois  in  bono,  ivl  m.  Peridental  membmne.  obt,  Osteo- 
blasts of  peridental  nionibrane.  ob2.  Osteoblasts  of  medullary  space,  pd  B,  Solid 
subperidental  and  subperiosteal  bone  with  imbedded  fibers,  ms,  Medullary  space 
formed  by  absorption  of  tlie  solid  subperidental  bone  witli  imbedded  fibers,  n,  B, 
Haversian  system  bone  without  fibers  l)uilt  around  the  medullary  space.     Noycs. 


Fig.  106. 


ft-        -^\-^.     ^       -%. 


*^ 


Fig.  107. 


Fig.    lilt).      From    scctimi    iii'-luclin^   ;i    |Hiili(in    ut'   the   ;tl\<'nl;ir    w.'ill.   ;iiicl    portions 

of    tlio    pciidoiital    incmhnmi',    sliowiiij;    tl stcohhists.      ;i.    lionc.       iiiiior    iiuirj^in    of 

alveolar  wall,  sliowiiifj  residual  fillers.  h.  Osteoblasts.  Developing  eells  are  seen 
in  the  neigliliorliood.  e.  Fibers  of  tlH>  peridental  membrane.  It  will  be  noted  that 
these  spring  from   the  bone  as  solid   fibers  and  immediatcdy   break  up  into   fasciculi. 

Fig.  107.  From  section  including  a  portion  of  the  alveolar  wall,  and  fibers  of 
the  peridental  inendirane  at  a  ]>oint  where  these  latter  are  large  and  compact,  and 
with  interfibrous  tissue  between  them,  a.  Bone  showing  the  large  residual  fibers, 
b.  Osteoblasts  filling  spaces  between  the  fibers,  c.  Principal  fibers  of  peridental 
niendjrane,  which  at  this  point  maintain  the  solid  form  far  out  from  the  bone, 
d.  Interfibrous  tissue  consisting  of  fibroblasts  and  fibers  which  lie  between  the  prin- 
cipal   fibers  and   TMirsue  an   indejiendent  course.     ('ompan>   with   Fig.    lOG. 


I'lCj.      1  !.•><. 


Fig     ins       'rransversc   soction,   shuwiiig   llu'   cvUnUv   flci.uMits.      Kb.    Fil)n)hlasts. 
EC,   Epithcliai   structures,     cb,  Cenientoblasts.     cm,   ConuMitum.      d.    Dnitin.      ^oyes. 


Fig.  109. 


Fig.  110. 


^^i^r*v. 


■..  --^i? 


S^S^?44;w'-" 


(/UO 


Fig.  111. 


Fig.  109.  (,'oiiu'iitiiiii  and  portion  of  tlio  peridental  membrane  from  tho  sheep. 
From  a  cross  section  of  the  tooth,  a,  ("ementum.  B,  Cetnentoblasts  lying  between 
the  fibers,  which  later  break  up  into  fasciculi  immediately  after  leaving  the  cementum. 
c,  e,  Cross  section  of  epithelial  clusters,  d.  Fibroblasts,  k,  Blood  vessels.  These  are 
accompanied  by  a  large  amount  of  intor-Jibrous,  or  indifferent  connective  tissue. 
F,  Nerve  bundle,  fi.  Fasciculi  of  fibers  pursuing  a  direction  different  from  the  main 
trend  of  the  principal  fibers. 

Fig.  110.  Cementoblasts  isolated  to  show  the  ]>cculiar  irregular  forms  of  these 
cells. 

Fig.  111.  Cementoblasts,  in  situ,  with  cross  sections  of  the  pi'incipal  fibers  of 
the  peridental  mendirane  of  the  pig,  from  a  section  cut  horizontal  to  the  surface  of 
the  cementum  and  including  these  cells.  It  will  be  seen  that  the  cementoblasts  fill 
all  the  space  not  occupied  by  the  principal  fibers. 


THE    ALVEOLAR    PEOCESSES.  53 

they  may  take.  It  is  interesting  to  follow  these  movements  and 
the  actions  and  reactions  of  the  tissues  in  their  natural  physio- 
logical dependence  upon  each  other  and  to  recognize  the  forces  at 
work. 

When  the  teeth  are  malposed. 

When  teeth  are  in  malpositions  from  some  cause,  and  the 
proper  devices  are  used  to  direct  the  teeth  back  into  normal  posi- 
tion —  or  better  said,  to  stimulate  the  growth  of  the  bones  in 
such  directions  as  to  bring  the  features  to  the  normal  fomi  and 
allow  the  teeth  to  come  into  proper  positions,  the  walls  of  the 
alveoli  about  the  teeth  will  grow  the  changes  to  accommodate 
the  movement.  In  cases  in  which  supernumerary  teeth  have 
diverted  one  or  more  teeth  from  their  nonnal  positions,  they  will 
come  to  their  normal  positions  soon  after  the  supernumerary 
teeth  are  removed ;  or  if  the  cuspids  have  not  fully  erupted  on 
account  of  lack  of  space,  they  will  move  into  place  if  the  proper 
space  is  made  for  them. 

When  we  have  learned  the  nature  of  these  physiological  rela- 
tions of  teeth,  their  alveoli  and  the  bones  which  form  them,  and 
these  forces  are  gently  stimulated  and  directed,  they  do  our 
bidding.  This,  taken  as  a  whole,  represents  very  briefly  the 
physiological  relations  of  the  teeth  and  the  growth  of  the  bones 
of  the  face  in  which  the  alveoli  and  the  alveolar  process  are  active 
participants. 

When  teeth  are  extracted. 

Finally,  if  further  evidence  were  needed  to  show  that  the 
alveolar  process  is  the  physiological  servant  of  its  related  tissues, 
and  especially  of  the  teeth,  the  results  which  occur  when  the  teeth 
are  lost  may  be  cited.  Straightway  the  alveoli  are  in  part  filled 
with  a  new  growth  of  bone  and  the  prominences  of  the  alveolar 
walls  are  removed  by  absorption.  Then  a  residual  alveolar  ridge 
is  all  that  is  left.  In  this  there  is  no  trace  of  the  former  alveoli. 
The  gingivae  which  rested  upon  the  crest  of  the  alveolar  process, 
with  all  of  their  appendages,  are  gone.  The  conditions  of  the 
formation  of  this  residual  alveolar  ridge,  the  influences  which 
give  good  form  and  which  give  bad  form,  are  very  important. 
They  are  discussed  elsewhere. 

Results  of  a  break  in  the  PERroENTAL  membrane. 

Another  point  of  im])ortance  that  we  should  know  early  in 
our  study  of  pathology  is  that  there  will   I'emain  no  alveolar 

♦7 


54  SPECIAL   DENTAL,   PATHOLOGY. 

process  over  any  part  of  the  root  of  a  tooth  without  a  peridental 
membrane.  The  peridental  membrane  makes  the  connection 
between  the  tooth  and  the  alveolar  process,  and  when  this  is 
broken  in  any  part  it  is  as  if  the  tooth  were  lost,  so  far  as  that 
particular  part  of  the  alveolar  process  is  concerned.  Straight- 
way this  portion  of  the  alveolar  process  is  absorbed  and 
removed. 

Movement  of  teeth  subsequent  to  extractions. 

Another  action  which  often  does  almost  incalculable  harm 
is  apt  to  follow  the  extraction  of  any  one  of  the  teeth.  Suppose, 
for  instance,  that  a  first  molar  is  extracted  when  the  person  is 
twenty  years  old  and  the  formation  of  the  arches  is  practically 
completed.  The  socket  of  this  tooth,  which  is  the  broadest  in  the 
mouth  in  the  mesio-distal  direction,  is  quickly  filled  in  with  bone, 
and  its  prominences,  with  the  gingivae  which  rested  upon  them, 
are  removed  by  absorption.  In  the  gum  tissue  which  covers  this, 
a  hard,  dense  cicatrix  is  formed.  The  fibers  of  the  peridental 
membrane,  which  formerly  passed  from  tooth  to  tooth  over  the 
crests  of  the  alveolar  septal  processes,  and  which  have  been  torn 
across  about  midway  between  the  two  teeth  both  to  the  mesial 
and  distal  of  the  extracted  one,  are  then  attached  to  this  cicatri- 
cial tissue.  This  shrinks  very  materially  as  the  rule.  This 
shrinkage,  with  the  pull  of  the  trans-septal  group  of  fibers,  tends 
to  drag  the  second  and  third  molars  forward,  causing  them  to 
lean  over  to  the  mesial,  so  that  their  occlusal  surfaces  do  not 
meet  the  opposite  teeth  properly.  The  bicuspids  may  be  simi- 
larly drawn  distally.  The  result  is  bad  occlusion  of  these  teeth, 
which  is  liable  to  lead  to  their  loss  some  time  in  the  future  by 
inducing  disease,  because  of  the  derangement  of  contact  points. 


THE    SALIVA. 


THE  SALIVA 

The  saliva  is  a  mixed  fluid,  the  most  important  constituents 
of  which  are  ptyalin,  mucus,  albumin  and  water  in  variable 
amounts,  containing  in  solution  the  following  salts :  potassium 
and  sodium  chloride,  potassium  sulphate,  sodium  carbonate  and 
calcium  carbonate  and  phosphate.  Certain  others  are  frequent 
constituents,  but  not  always  present  in  appreciable  quantities. 
Several  of  these  constituents  may  be  present,  or  absent;  these 
may  assume  some  importance  in  general  descriptions.  The 
presence  of  potassium  sulphocyanide  has  given  rise  to  a  good 
deal  of  discussion  in  connection  with  the  study  of  immunity  to 
dental  caries.  The  following  data  will  give  a  better  view  of  the 
constituents  of  saliva  :* 

Water  994.203 

Solids : 

Mucin  and  epithelial  cells 2.202 

Ptyalin  and  albumin 1.390 

Inorganic  Salts 2.205 

5.797 


1.000.000 
(Potassium  sulphocyanide  0.041.) 

It  might  be  said,  then,  that  the  saliva  consists  of  water,  in 
which  there  are  suspended  ptyalin,  mucus,  albumin  and  the 
salts  which  are  mentioned  above,  and  any  one  of  them  may  be 
abundant  or  scant.  The  amount  of  these  constituents  is  very 
variable. 

I  shall  not  in  the  present  writing  undertake  any  extended 
nor  very  critical  description  of  the  saliva,  neither  of  the  mixed 
fluids  nor  of  its  constituents,  but  sliall  give  only  an  outline  of 
these  fluids  as  they  are  observed  in  the  mouth  in  tlie  practice  of 
dentistry.  The  composition  of  the  saliva  is  very  comi)lex,  as 
will  be  seen  from  the  table,  but  really  it  is  very  much  more 
complex  than  the  table  would  indicate,  by  reason  of  its  great 
variability. 

Some  specimens  of  saliva  are  very  mucilaginous,  others  are 
very  thin  and  waterj^     Certain  specimens  seem  to  liave  large 

*  American  Text-Bonk  of  Pliyaiologry.     Win.  IT.  TTowoII. 


56  SPECIAL   DENTAL   PATHOLOGY. 

amounts  of  albumin,  others  seem  to  be  almost  destitute  of  albu- 
min. The  albumin,  mucus  and  other  similar  substances  are 
known  as  the  colloids  of  the  saliva.  In  most  specimens  of  saliva, 
scattering  spherules  may  be  found  which  have  generally  been 
spoken  of  as  salivary  corpuscles.  In  some  specimens  these  are 
very  abundant.     These  will  be  discussed  a  little  later. 

The  loading  of  the  saliva  with  carbon  dioxid  is  practically 
continuous,  and  there  are  some  other  gases  generally  present 
in  the  fluid.  Indeed,  from  the  fact  that  car1)on  dioxid  is  pro- 
duced in  the  blood  and  tissue  juices  in  the  metabolism  going  on 
in  the  body,  and  is  excreted  mostly  by  the  lungs,  it  will  be  seen 
that  this  amount  will  be  variable  within  certain  limits,  but  that 
the  gas  will  also  be  present  in  the  secretions  and  excretions. 
The  saliva  always  contains  a  variable  proportion  of  this  gas, 
which  may  be  removed  from  it  by  reducing  the  atmospheric 
pressure  on  the  liquid  by  the  use  of  an  air  pump,  and  its  quan- 
tity may  be  determined.  The  relative  quantity  of  the  other 
constituents  of  the  saliva  may  be  detennined  by  chemical 
processes.  For  a  full  description  of  the  saliva  constituents,  I 
would  recommend  the  student  to  works  on  physiology,  and 
especially  the  American  Text-Book  of  Physiology,  edited  by 
Prof.  win.  H.  Howell,  Ph.D.,  M.D.  This  statement,  with  a  gen- 
eral reading  of  one  or  two  recent  books  upon  physiologj^,  in 
which  studies  of  this  subject  are  given  in  extenso,  will  prepare 
a  student  for  special  observations  which  I  shall  detail  here. 

Ptyalin. 

Ptyalin  is  a  digestive  body  found  in  the  saliva.  It  is  an 
unorganized,  ferment  body,  or  enzyme  of  the  amylolytic  type, 
which  induces  a  peculiar  action  in  starch,  converting  it  into 
sugar.  This  action  is  produced  very  quickly  in  cooked  starch, 
but  in  raw  starch  is  so  slow  as  not  to  be  appreciable  in  the  ordi- 
nary chewing  of  food.  The  effect  of  cooking  upon  starch  is  to 
break  the  membrane  of  the  starch  granule  and  expose  the  starch 
innnediately  to  the  action  of  ptyalin;  while  in  raw  starch  the 
granule  is  surrounded  by  a  membrane  of  cellulose,  which  pre- 
vents the  ready  action  of  the  ptyalin  upon  the  starch  enclosed. 
Hence,  much  greater  time  is  required  for  the  digestion  of  raw 
starch.  The  action  of  the  ptyalin  of  the  saliva  upon  cooked 
starch  is  so  prompt  that  it  may  be  readily  appreciated  by  taking 
a  piece  of  ordinary  bread  in  the  mouth  and  chewing  it.  In  the 
first  acts  of  chewing  this  bread  (taking  no  water),  it  will  be 


Fig.  112. 


Fig.    112.      A    section    outliiifr    diagonally    through    the    root.      A,    Network    of 
epithelial  cords;    D,  dentin;    cm,  ccmentum.     Noyes. 


Fig.  11.3. 


Fig.  114. 


x: 


Fig.  115. 


Fig.  113.  Strings  of  epithelial  cells  from  peridental  membrane.  From  a  sec- 
tion taken  horizontal  to  the  surface  of  the  cement  urn,  hut  a  verv  slight  distance 
from   it.     Cross  cuts  of  these  are  seen  at   c,  c.   in    Fiyuic   1(1!). 

Fig.  114.  Transverse  section  of  tiic  pciidcnlal  mciiiliraiic  in  the  gingival  por- 
tion, showing  the  position  of  the  eiiitlidial  cuds.  'I'lir  loop  at  A  is  shown  more 
liighly  magnified  in  Fig.  116.     Noticti. 

Fig.  115.  Epithelial  cells  from  near  tlie  gingival  border  of  the  peridental 
membrane,     a,  a,  a,  Individual  epithelial  cells,     b,  b,  Caj)illary  vessel. 


Fm.   116. 


Fig.  llli.  Kpitlirliiil  stnictnres:  v.c.  K|.itlii'li;i 
hiinen.  cb,  Coinciitohlasts.  cm,  (Viiu'iitmii.  n.  Dnitiii 
Noyes. 


iiiii.    :i|i|),i  liMil  ly     sliiiwiiii;     :i 
'liis  Idiip  is  sct'ii  ill   Fi^r.   114. 


Fig.  117. 


Fig.  117.  A  famous  dental  cartoon,  of  Rowlandson,  published  in  1787,  depict- 
ing the  operation  of  transplanting  teeth  from  the  mouths  of  the  poor  to  those  of 
the  wealthy.  This  operation  was  made  popular  by  the  publication  in  1778  of  the 
work  of  Sir  John  Hunter,  entitled  '"A  Practical  Treatise  on  the  Diseases  of  the 
Teeth,"  in  which  he  describes  the  operation. 

Acconling  to  the  historian  Guerini,  Abulcasis,  an  Arabian,  1050-1122,  first  men- 
tioned replantation,  but  to  Andjoisc  Pare,  1517-1592,  credit  should  be  given  for 
having  first  jKn-formed  and  described  the  operation  of  transplantation.  Original  of 
this   illustration   in   Xorthwe^tcni    riiivorsity   Dental    Museum. 


Fig.  118. 


Fig.  119. 


Fig  lis  K,.i,r.Hl.i<-ticui  uf  -a  radiuyntph  of  i.n  i.]'!"''-  '•<-"tr:il  uu-isor  implanted 
bv  Dr  Thomas  L.  GilnuT.  Wl,...,  this  ra.li..Kraph  was  taken  the  tooth  ha.l  l.oon  in 
the  alveolus  nearly  three  years.  It  Avill  be  noticed  that  the  tooth  ha.l  been  cut  away 
by  absorption  from  either  side  almost  to  the  root  filling. 

Fig  119  A  bicuspid  tooth  which  wis  implanted  ami  remained  in  the  alveolus 
about  tiiree  vears.  The  extensive  absorption  of  the  root  is  very  .dearly  shown. 
Specimen  fro'm  Northwestern  University  Dental  Museum. 


/ 


';:^ 


''<i 


♦.'■'■'« '^  5^  ^> 


Fig.  121. 


Fig.  120.  Portion  of  the  labial  alveolar  wall  of  an  incisor  that  is  being  absorbed, 
a,  a,  Portion  of  the  inner  layer  of  the  periosteum,  b,  b,  Bone  forming  a  jiortion  of 
the  labial  wall  of  the  alveolus.  It  will  be  observed  that  it  contains  a  number  of 
Haversian  canals,  h,  h.  c,  c,  A  portion  of  the  peridental  membrane,  d,  d,  d,  Osteo- 
clasts which  are  in  the  act  of  removing  the  bone,  thus  widening  the  alveolus,  e,  Space 
from  which  a  largo  osteoclast  has  probably  fallen  during  the  preparation  of  the  sec- 
tion. It  will  be  noticed  that  wliere  the  osteoclasts  are  removing  the  bone,  the  fibers 
of  the  peridental  membrane  are  detached  and  some  little  space  is  occupied  by  tissue 
of  embryonal  type,  but  in  the  spaces  between  the  groups  of  osteoclasts  the  fibers  are 
firmly  attached  to  the  bone.  At  f,  there  seems  to  be  a  little  new  bone  formed  to 
which  fibers  are  attached.  In  this  way  bone  seems  to  lie  removed,  part  by  part,  and 
the  attachment  of  the  membrane  maintained. 

Fig.  121.  Portion  of  the  alveolar  wall  of  a  cuspid  tooth  of  an  old  person,  show- 
ing absorptions,  a,  a,  Portion  of  the  peridental  membrane,  b,  b,  Portion  of  bone 
that  seems  to  have  been  built  on  to  supply  an  area  of  previous  absorption,  e,  A 
recent  absorption  area.  At  f,  three  osteoclasts  are  seen.  It  will  be  noted  that  the 
fibers  of  the  peridental  membrane  are  detached  throughout  this  area  of  absorption 
and  the  space  is  occupied  by  tissue  of  embryonic  type.  It  should  also  be  noted  that 
the  Haversian  systems  of  the  bone  had  been  cut  into  by  the  previous  absorption, 
removing  portions  of  the  rings  of  the  Haversian  systems.  Residual  fibers  are  seen  in 
the  bone  b.  but  there  are  none  in  the  Haversian  bone  c. 


THE    SALIVA.  57 

noted  that  it  is  moistened  by  the  saliva.  In  a  very  short  time, 
the  chewing  proceeding,  a  sweetish  taste  will  be  noted,  and  pro- 
ceeding further  with  the  chewing,  until  the  bread  is  converted 
into  a  pulp,  this  sweet  taste  becomes  a  prominent  feature.  This 
is  the  result  of  the  conversion  of  the  starch  into  sugar  by  the 
ptyalin  of  the  saliva,  and  is  an  experiment  which  any  one  may 
try  and  get  an  appreciation  of  the  quick  action  of  this  body  upon 
the  starches.  As  quick  as  this  action  is,  the  reaction  upon  starch 
is  never  complete  in  the  mouth,  and  when  it  passes  into  the 
stomach  the  action  of  the  hydrochloric  acid,  which  it  meets  with 
there,  destroys  the  further  action  of  the  ptyalin  and  a  final 
completion  of  the  digestion  of  the  starch  is  performed  by  the 
digestive  bodies  of  the  pancreas,  especially  the  amylopsin,  after 
its  arrival  in  the  pyloric  portion  of  the  intestine.  It  is  said  the 
ptyalin  usually  acts  upon  the  starch  alone,  but  I  think  this  is  not 
quite  true.  There  is  some  action  upon  other  ingredients  of  food 
as  well,  but  it  is  so  slow  in  the  ordinary  chewing  of  foods  as  not 
to  be  very  appreciable  and  can  not  be  reckoned  with  as  a  general 
action  of  this  digestive  body.  This  is  the  first  act  of  digestion, 
which  takes  place  when  food  is  introduced  into  the  mouth,  and 
is  practically  the  only  act  of  digestion  which  occurs  within  the 
mouth  itself. 

The  action  of  ptyalin  in  the  mouth,  however,  is  very  much 
wider  than  that  represented  here  in  the  chewing  of  starchy 
foods.  The  starchy  foods  are  pasty  and  they  are  certain  to  stick 
more  or  less  about  the  teeth  and  in  the  embrasures,  and  also  in 
the  interproximal  spaces,  if  the  septal  gingivje  are  a  little  bit 
short.  After  a  meal  the  effect  of  the  ptyalin  in  dissolving 
starch  will  clean  up  all  of  these  pasty  masses  and  remove  them 
by  solution  in  a  very  short  time.  This  is  another  of  the  very 
important  influences  of  ptyalin  on  the  health  of  the  membranes 
of  the  teeth.  If  it  were  not  for  this  reaction  of  ptyalin,  micro- 
organisms would  grow  very  luxuriantly  in  these  pasty  masses 
and  would  thus  increase  the  injury  to  the  tissues  in  all  cases  of 
irritation  or  inflammation. 

Ptyalin  is  common  to  man  and  to  the  herbivorous  and 
omnivorous  animals,  but  is  generally  absent  in  the  carniverous 
animals.  From  observations  I  have  made  the  domestic  dog 
seems  to  have  developed  a  secretion  containing  some  ptyalin. 
This  perhaps  has  been  developed  by  its  habit  of  eating  cooked 
starches  with  which  more  or  less  greasy  or  oily  compounds  are 
mixed.     This  probably  does  not  occur  in  the  wolf,  the  progenitor 


58  SPECIAL   DENTAL.   PATHOLOGY. 

of  the  domestic  dog,  and  does  not  occur  in  the  cat  family,  nor 
indeed  in  any  other  animal  which  is  limited  to  flesh  as  its  diet. 

Mucus. 

Mucus  is  one  of  the  principal  colloids  of  the  saliva.  It  has 
a  close  resemblance  to  albumin  and  is  probably  a  nucl co-all )um in 
in  its  general  make-up.  It  must  be  understood  that  mucus 
appears  throughout  the  body  and  body  juices,  and  its  presence 
is  seen  mostly  upon  what  we  term  the  mucous  membrane 
throughout  the  mouth  and  the  digestive  tract,  also  in  other 
regions,  such  as  the  nasal  passages,  the  trachea,  the  tubes  of  the 
lungs,  the  urinary  bladder,  and  in  other  cavities  of  the  body. 
In  these  various  positions,  there  is  much  difference  in  the  char- 
acter of  the  mucus,  depending  upon  certain  elements  in  its  com- 
bination. We  will  not  go  into  these  questions  here,  but  will 
discuss  only  those  which  are  of  special  interest  to  the  dentist, 
and  avoid  all  of  the  chemical  questions,  further  than  those 
included  in  this  statement.  Any  one  who  wishes  to  pursue  this 
subject  further  will  find  it  fully  exemplified  in  the  more  com- 
plete works  on  physiology.  I  would  refer  the  student  particu- 
larly to  Howell's  American  Text-Book  of  Physiology,  page  1019. 

The  saliva  contains  a  considerable  proportion  of  mucus. 
Wlien  this  is  abundant  the  saliva  will  be  sticky  and  ropy.  This 
ropiness  may  in  a  degree  be  determined  by  touching  the  finger 
to  the  saliva  and  drawing  it  away,  noting  how  far  a  thread  of 
it  can  be  drawn.  In  very  ropy  saliva  we  may  sometimes  draw 
out  this  thread  to  the  arm's  length.  In  other  saliva  again, 
where  the  mucus  is  scant,  one  can  not  draw  out  a  thread  more 
than  a  very  few  inches.  These  differences  will  present  the 
different  proportions  of  mucus  in  the  saliva. 

The  mucus  is  formed  in  the  salivary  glands.  Only  cells,  or 
groups  of  cells,  in  the  glands  secrete  the  mucus ;  other  parts  of 
the  glands  secrete  the  watery  portion.  The  mucus  is  immedi- 
ately dissolved  in  the  watery  secretions  from  other  portions  of 
the  same  glands  and  flows  through  the  ducts  and  is  discharged 
into  the  mouth  in  this  mixed  form.  There  are  other  mucous 
follicles  in  the  mucous  membranes  of  the  mouth,  in  some  regions 
very  plentifully  distributed,  which  most  of  the  physiologists 
whom  I  have  read  ignore.  These  are  particularly  plentiful 
in  the  fauces,  and  serve  especially  to  lubricate  the  bolus  of 
food  for  swallowing.  There  are  also  mucous  glands  scattered 
through  the  mucous  membrane  of  the  mouth,  but  these  are  less 
plentiful.     From  these  one  may  see  mucus  in  its  pure  form, 


THE    SALIVA.  59 

unmixed  with  the  saliva.  In  the  mouths  of  persons  who  have 
a  considerable  amount  of  mucus  in  the  saliva,  these  mucous 
glands  of  the  mouth  are  unusually  active.  If  one  will  wash  the 
roof  of  the  mouth  with  a  jet  of  water  from  the  syringe,  then  dry 
it  with  a  napkin,  and  place  the  finger  in  such  a  position  that  the 
tongue  can  not  wipe  off  and  rewet  the  roof  of  the  mouth,  one 
will  note  at  least  a  few  little  globules  of  mucus  appearing. 
If  one  of  these  is  touched  with  the  finger,  and  the  finger  is  then 
slowly  and  carefully  drawn  away,  one  may  be  able  to  pull  out  a 
thread  of  this  mucus  a  considerable  distance,  possibly  as  long 
as  the  arm  will  reach. 

This  represents  the  peculiar  characters  of  the  mucus.  It  is 
sticky,  hangs  to  everything  it  touches,  and  when  mixed  with  the 
general  fluid  of  the  mouth  makes  that  ropiness  of  which  some 
people  complain.  The  mucus  is  the  substance  in  the  saliva 
which  coats  over  the  teeth,  the  mucous  membrane,  and  every 
part  of  the  mouth,  and  gives  the  slippery  character  which  we 
may  feel  with  the  fingers  during  an  examination.  All  of  the 
mucus  may  be  removed  in  a  few  moments  by  jets  of  water  from 
the  syringe,  and  if  the  mouth  is  dried,  this  slipperyness  will 
have  disappeared.  This  is  done  more  or  less  every  time  one 
drinks  water,  or  more  especially  by  rinsing  the  mouth  thor- 
oughly with  water.  The  difference  in  sensation  in  the  mem- 
branes of  the  mouth  when  covered  with  mucus,  and  that  after 
the  mucus  has  been  washed  away,  is  quite  noticeable.  The 
effect  of  washing  the  mouth  is  to  remove  the  mucus.  Within  a 
very  few  minutes  the  surface  of  the  mouth  will  be  recoated  with 
mucus. 

The  function  of  mucus  is  a  mechanical  one.  Many  physi- 
cians speak  of  this  as  the  only  function  of  the  mucus,  and 
usually  speak  of  it  only  as  the  lubricant  of  the  bolus  of  food  for 
swallowing,  rendering  it  slippery  for  this  particular  purpose. 
This  is  entirely  too  meager  a  description  of  the  function  of  the 
mucus.  The  whole  of  the  mucous  membrane  of  the  mouth  is 
made  slippery  by  the  presence  of  mucus  upon  it.  The  teeth  and 
every  part  of  the  mucous  membrane  and  the  gingivjB  are  coated 
with  mucus.  In  the  act  of  chewing  it  is  intimately  mixed  with 
the  food  and  causes  the  food  to  slip  easily  over  the  surface  of  the 
teeth,  gingiv.T,  and  the  gums,  and  prevents  most  foods  from 
sticking  to  these  parts  by  its  interposition  between  them  and 
the  mucous  membrane.  In  this  way  it  is  incorporated  into  each 
mouthful  of  food  and  facilitates  the  act  of  mastication.  We 
could   scarcely  chew  food  without   it.    It  causes   food,   wheni 


60  SPECIAL   DENTAL    PATHOLOGY. 

crushed  by  the  teeth,  to  run  smoothly  through  the  embrasures  to 
either  side  of  the  arch.  It  also,  in  the  act  of  chewing,  permits 
the  food  to  be  easily  thrown  back  upon  the  teeth  by  the  muscles 
of  the  tongue  and  of  the  cheeks.  Then  by  successive  closures  of 
the  teeth,  the  food  moves  back  and  forth  repeatedly  in  the  act  of 
chewing.  This  is  just  as  important  a  function  of  the  mucus  as 
is  the  lubrication  of  the  bolus  for  the  act  of  swallowing.  It  is 
true  that  this  is  a  mechanical  function,  but  the  ordinary  amount 
of  mucus  found  in  the  normal  saliva  is  entirely  sufficient  to 
perform  this  lubrication  efficiently.  Some  persons,  when  very 
much  tired  out  and  suffering  for  the  want  of  water,  will  remem- 
ber the  difficulty  of  taking  food  under  such  conditions.  Lacking 
this  slipperyness  caused  by  the  mucus,  food  becomes  unman- 
ageable in  the  mouth. 

AXiBUMIN. 

Albumin  is  not  usuallj^  reckoned  as  a  normal  constituent  of 
the  saliva,  but  it  is  frequently  present.  I  know  of  no  function 
that  this  albumin  is  destined  to  perform  in  the  mouth,  under 
normal  conditions,  and  I  suppose  it  is  there  by  accident  or  some 
perversion  of  the  secretive  processes.  In  some  mouths  it  is 
quite  abundant  and  in  others  it  can  be  detected  only  by  very 
close  chemical  scrutiny,  the  amount  is  so  small.  The  indications 
of  the  presence  of  albumin  in  the  saliva  have  never  been  at  all 
carefully  studied,  so  far  as  I  know.  It  seems  to  have  been 
regarded  as  unimportant  by  physiologists  and  pathologists. 

A  certain  amount  of  albumin  is  found  in  the  urine,  and  in 
other  secretions  as  well,  including  the  saliva,  and  it  is  regarded 
as  a  state  in  which  albumin  is  being  lost  from  the  system 
through  the  secretions  generally,  but  through  certain  secretions 
more  especially.  Albumin  urea,  however,  indicates  a  diseased 
state  of  importance  and  is  always  looked  for  very  closely  by 
physicians. 

Salivary  corpuscles,  so  called. 

A  number  of  those  writing  of  the  saliva  speak  of  salivary 
corpuscles  found  in  it,  and  there  has  been  some  speculation  as  to 
what  these  were  and  what  function  they  might  have.  Most  of 
our  physiologists  speak  of  them  as  the  remains  of  leucoytes 
which  have  wandered  into  the  saliva  and  are  undergoing  disin- 
tegration. I  have  searched  a  considerable  number  of  the  more 
recent,  and  some  of  the  older,  works  on  physiology,  and  find  no 
mention  in  any  of  them  of  the  existence  of  globulin  in  spherical 


THE    SALIVA.  61 

form.  My  search,  however,  has  not  been  exhaustive,  and  I  may 
have  missed  some  announcement  of  that  fact.  They  have  not 
attracted  very  general  attention,  however. 

In  the  course  of  my  work  I  happened  to  run  onto  these,  and 
by  comparison  it  was  easily  made  out  that  they  were  primary 
spherules  of  globulin,  the  same  as  the  spherules  that  are  poured 
out  with  the  saliva  in  the  formation  of  salivary  calculus,  which 
will  be  described  later.  I  requested  my  laboratory  assistants  to 
determine  the  matter  of  identity  or  nonidentity  by  staining 
methods,  in  which  they  found  that  the  two  spherules  were  iden- 
tical in  their  reaction  with  a  considerable  number  of  stains ;  and 
as  they  looked  alike  and  were  the  same  size,  they  were  satisfied 
that  they  were  actually  the  same.  Therefore,  I  may  state  from 
my  own  determination  made  in  a  similar  manner,  and  from  the 
determinations  as  repeated  by  my  assistants,  that  the  so-called 
salivary  corpuscle  appears  to  be  a  spherule  of  globulin. 

They  are  generally  round,  but  not  always  a  perfect  sphere. 
They  have  no  limiting  membrane,  and  the  margins  are  not  infre- 
quently somewhat  ragged.  They  may  be  seen  without  staining, 
and  are  fairly  translucent,  the  central  parts  showing  dark,  while 
the  margins  show  light.  The  finding  of  many  of  these  in  the 
saliva  indicates  that  globulin  is  being  poured  into  the  mouth 
with  the  saliva. 


62  SPECIAL   DENTAL   PATHOLOGY. 


THE   INVESTING   TISSUES   OF   THE   TEETH  — 
GINGIVAE,  PERIDENTAL  MEMBRANE, 
GEMENTUM  AND  ALVEOLAR  PROCESS 


DISEASES  AND  TREATMENT 

IN  the  consideration  of  disease  beginning  at  the  gingival  mar- 
gin of  the  peridental  membrane  the  conditions  might  seem 
to  be  very  different  from  those  associated  with  beginnings  of 
dental  caries,  death  of  the  pulp  and  alveolar  abscess,  yet  the  care 
of  the  mouth  necessary  to  the  prevention  of  all  of  these  condi- 
tions is  practically  the  same. 

We  may  find  inflammatory  conditions  in  the  gingivae  of  the 
child,  which,  while  they  need  attention,  may  be  regarded  as 
somewhat  trivial  in  that  they  tend  to  get  well  with  little  diffi- 
culty as  a  rule.  Serious  disease  of  the  gingivae  does  not  very 
often  occur  in  children.  During  childhood  the  free  gingivae  are 
abundant  and  cover  a  considerable  portion  of  the  crowns  of  the 
teeth.  The  portion  of  the  tissue  in  which  inflammation  begins 
is  usually  that  which  laps  upon  the  crowns  of  the  teeth,  rather 
than  the  deeper  portions  lying  nearer  the  gingival  line.  It  is 
the  extension  of  inflammation,  involving  the  tissues  at  the  gin- 
gival line  that  is  most  dangerous  to  the  future  of  the  teeth. 
While  all  of  this  is  true,  inflammations  of  the  gingivae  of  chil- 
dren should  be  guarded  against  as  much  as  possible,  and  cases 
occurring  should  have  prompt  treatment. 

Beginning  with  early  adult  life  the  greatest  care  should  be 
taken  as  to  diseases  of  the  gingivae,  for  at  that  time  the  gingivae 
have  shrunken  to  their  normal  length  for  adult  life.  Injuries 
are  then  apt  to  become  more  serious  and  suppurations  are  liable 
to  begin  at  the  gingival  line,  and  cut  away  the  tissues,  forming 
pus  pockets.  After  this  has  occurred  and  the  pockets  have  made 
considerable  progress,  a  cure  becomes  practically  impossible. 
To  be  effective,  whatever  is  done  in  the  way  of  prophylaxis 


INVESTING    TISSUES.      DISEASES    AND    TREATMENT.  t)3 

against  this  disease  must  be  undertaken  before  such  an  occur- 
rence. This  requires  of  the  dentist  that  he  make  careful  exam- 
ination of  the  gingivae  of  every  patient,  and  if  there  are 
inflammations  they  should  have  immediate  and  most  painstaking 
treatment.  No  matter  what  may  be  the  cause  of  such  inflamma- 
tion, it  should  be  searched  out  to  the  limit,  found  and  removed. 
In  this  way  I  am  persuaded  from  past  experience  that  the  vast 
majority  of  these  cases  can  be  prevented  by  removing  the  dan- 
ger in  its  inception. 

This  requires  quite  as  close  a  watch  of  patients  as  that 
necessary  to  prevent  diseases  of  the  pulp  in  children.  There 
should  be  a  wide  range  as  to  the  frequency  of  the  examinations 
of  different  patients.  Some  should  be  seen  regularly  every  two 
or  three  months,  others  even  more  frequently,  while  others 
present  a  degree  of  health  of  these  parts  which  will  permit  of 
the  examinations  being  placed  more  widely  apart. 

The  impression  made  upon  the  patient  as  to  the  importance 
of  this  condition  has  very  great  value,  and  should  be  carefully 
made  by  the  dentist,  so  that  the  patient  will  not  neglect  to  con- 
sult the  dentist  as  often  as  may  be  desired  for  examinations. 
These  little  inflammations  —  and  they  often  are  seemingly  triv- 
ial —  are  usually  painless  and  they  may  pass  on  to  a  sup- 
purative state,  which  will  do  great  harm  before  the  patient  will 
realize  that  anything  is  wrong.  The  insidiousness  of  this  class 
of  diseases  is  such  that  not  many,  even  dentists,  have  been  regu- 
larly in  the  habit  of  noticing  them  during  the  early  stages.  A 
little  redness  here  or  there  seems  to  be  of  no  consequence,  and 
after  a  time  when  the  case  has  gone  too  far  for  remedies  to  be 
effective,  the  dentist  will  find  the  disease  very  serious  and  incor- 
rectly suppose  that  it  is  comparatively  recent  in  its  beginning. 

The  matter  of  the  deposits  of  salivary  calculus  about  the 
necks  of  the  teeth  and  impinging  upon  the  free  gingivae,  is  also 
important.  This  will  cause  inflammation  of  the  gingivae  and 
result  in  shortening  and  blunting  of  the  margins  or  crests  of 
the  gingivae,  and  even  when  they  are  brought  to  a  healthy  con- 
dition after  removal  of  the  calculus,  they  will  not  be  so  good  as 
they  were  before.  The  very  thin  margins,  which  formerly  came 
up  about  the  teeth,  will  have  become  thickened  so  as  to  form 
better  lodging  places  for  debris  and  calculus.  Each  consider- 
able deposit  that  is  allowed  to  harden  in  such  position  gives  its 
increment  of  injury  to  the  tissue,  making  it  worse  and  worse  as 
to  the  collection  of  lodgments.  For  this  reason  every  patient, 
in  whose  mouth  a  deposit  of  calculus  is  discovered,  should  be 


64  SPECIAL   DENTAL   PATHOLOGY. 

trained  to  prevent  this  and  avoid  the  injury  which  occurs  as  a 
result  of  occasionally  permitting  the  calculus  to  become  hard. 
Finally,  the  whole  question  of  prophylaxis  as  applied  to 
this  condition  depends  upon  the  practical  care  of  the  dentist, 
his  training  in  the  observation  of  the  inflammations  of  the 
gingivas  caused  by  slight  deposits,  and  his  influence  in  bringing 
his  patients  to  a  realization  of  the  danger,  as  an  inducement  to 
them  to  adopt  certain  systems  of  personal  care  calculated  to 
prevent  the  occurrence  or  recurrence  of  such  inflammations. 
This  will  be  taken  up  step  by  step  and  developed  along  the  lines 
indicated  by  modern  research.  Observation  has  led  me  to  believe 
that  the  injuries  caused  by  such  deposits  may  be  prevented  in 
the  mouths  of  practically  all  persons. 

Brief  Historical  Review  or  the  Development  of  Our  Knowl- 
edge OF  THE  Diseases  of  the  Investing  Tissues. 

As  I  look  back  over  the  field,  the  dental  profession  has 
never  been  disposed  to  give  the  diseases  of  the  gingivae  and 
peridental  membrane  accurate  and  careful  study  as  to  patho- 
logical conditions.  For  what  seems  to  me  to  have  been  a  long 
time  after  I  began  practice,  no  attention  was,  witliin  my  knowl- 
edge, given  to  these  conditions,  except  to  remove  calculus  when 
patients  appeared  with  incrustations  upon  their  teeth. 

Names  applied  to  diseases  of  the  investing  tissues.  The 
group  of  diseases  of  the  investing  tissues  of  the  teeth  have, 
without  differentiation,  had  more  names  than  any  other  group 
of  pathological  conditions  occurring  in  the  mouth,  and  new 
names  are  being  continuously  introduced.  The  earliest  writers 
were  content  with  the  terms  spongy  gums,  inflamed  gums, 
loosening  of  the  teeth,  or  others  of  similar  import.  Generally, 
the  entire  subject  was  disposed  of  in  a  single  paragraph,  or  at 
most  in  a  page  or  two. 

In  the  sixties  and  early  part  of  the  seventies.  Dr.  J.  M. 
Riggs,  of  Hartford,  Connecticut,  brought  this  subject  promi- 
nently to  the  notice  of  the  profession  by  clinics  which  he  made 
before  dental  societies,  rather  than  by  writing.  For  a  time 
Dr.  Riggs'  methods  had  quite  a  following,  and  the  condition 
came  to  be  called  Riggs'  Disease.  This  term  is  still  seen  occa- 
sionally in  the  literature. 

The  term  Pyorrhea  Alveolaris  was  proposed  by  Dr.  F.  H. 
Rehwinkel,  of  Chillicothe,  Ohio,  in  a  paper  before  the  American 
Dental  Association  at  its  meeting  in  Chicago  in  1877.  It  may 
be  said  that  this  name  lias  become  the  most  popular  term  for 


INVESTING    TISSUES.      DISEASES    AND    TREATMENT.  65 

the  group  of  diseases  of  the  tissues  investing  the  teeth.  The 
term  pyorrhea  alveolaris  means  the  running  of  pus  from  the 
alveoli.  It  covers  too  much  and  does  not  properly  describe  the 
disease  to  which  it  is  applied.  I  do  not  intend  to  use  this  term 
in  this  writing.  This  is  not  from  any  captious  objection  to  it 
on  my  part,  but  because  I  wish  to  describe  the  several  diseases 
under  different  names  to  distinguish  them  and  make  each  as 
clear  as  possible.  This  I  could  not  do  under  the  single  term 
pyorrhea  alveolaris.  In  studies  of  the  cast  of  mind  of  people, 
dentists  as  well  as  others,  it  will  be  observed  that  in  order  for  a 
particular  thing  to  be  understood  as  a  separate  and  distinct 
entity,  it  must  have  a  distinct  name,  and  this  is  as  true  of  disease 
as  it  is  of  anything  else. 

In  1882,  in  a  paper*  before  the  Illinois  State  Dental  Society, 
I  proposed  the  term  Phagendenic  Pericementitis  to  apply  to  that 
form  of  disease  in  which  pockets  were  formed  alongside  the 
roots  of  the  teeth.  This  term  goes  no  farther  than  to  locate  and 
describe  the  destructive  character  of  the  inflammation  of  the 
peridental  membrane,  a  fact  well  known.  This  term  phagedenic 
was  formerly  much  used  in  describing  certain  ulcers  which 
refused  to  heal  and  tended  to  the  progressive  destruction  of  the 
soft  tissues.     It  means  to  devour  or  destroy  by  eating  away. 

The  term  Chronic  Suppurative  Pericementitis,  which  means 
the  same  and  is  more  readily  understood,  will  be  used  in  this 
book. 

In  the  paper  referred  to  above,  I  proposed  the  terms  Calcic 
Gingivitis  and  Calcic  Pericementitis,  as  describing  the  form  of 
disease  caused  by  accumulations  of  salivary  calculus  upon  the 
teeth.  I  believed  the  conditions  presented  well  worthy  of  this 
distinction.  Similar  terms  will  be  used  in  this  book  as  a  part 
of  a  simple  classification  of  the  several  types  of  inflammation 
which  will  be  described. 

The  term  Alveolitis  was,  I  believe,  first  used  by  Dr.  Adolph 
Witzel,  of  Germany.  It  is  being  used  by  a  number  of  American 
writers  and  is  frequently  seen  in  the  literature.  If  this  term,  by 
its  original  definitions,  had  been  made  to  apply  to  the  soft  tis- 
sues within  the  alveoli  of  the  teeth  —  the  peridental  membrane 
—  it  would  not  have  been  far  from  correct.  But  it  seems  to 
have  been  proposed  and  defined  with  the  idea  that  the  principal 
seat  of  the  disease  is  in  the  margins  of  the  alveolar  processes. 
This  is,  to  my  mind,  an  incorrect  statement  of  the  conditions. 


*  Phagedena  Pericementi.    Proceedings  Illinois  State  Dental  Society,  1882,  p.  93, 


66  SPECIAL   DENTAL   PATHOLOGY. 

as  the  alveolar  process  is  the  last  of  the  investing  tissues  to 
become  involved.  Dento- Alveolar  Pyorrliea  and  Interstitial  Gin- 
givitis are  occasionally  seen  in  the  literature,  as  are  other  terms 
referring  to  diseases  of  the  peridental  membrane,  which  have 
their  beginning  at  the  gingival  margins. 

Dr.  Riggs'  TREATMENT.  One  of  the  oldest  discussions  of 
Dr.  Riggs'  treatment  occurs  following  a  paper  on  Salivary  Cal- 
culus read  by  Dr.  Thos.  B.  Hitchcock  before  the  Connecticut 
Valley  Dental  Society  in  1869,  and  reported  in  the  Dental  Cos- 
mos, Vol.  XI,  1869,  p.  412.  At  this  time  Dr.  Riggs  brought 
before  this  society  a  patient,  Dr.  Goodrich,  for  whom  he  had 
operated  before  this  same  society  two  years  earlier.  Dr.  Riggs 
stated  that  he  had  been  operating  in  the  same  way  for  twenty- 
five  years,  and  the  majority  of  his  cases  were  successful. 

In  those  days  the  essays  and  discussions  of  the  Dental 
Societies  were  not  reported  so  fully  as  in  more  recent  times, 
and  it  is  very  difficult  to  trace  the  date  of  origin  of  important 
discoveries  or  events  which  occasionally  become  of  special  inter- 
est. 

Dr.  Riggs  made  some  important  statements  regarding  his 
treatments,  which  were  published  in  the  Dental  Cosmos  in  1882, 
p.  524.  This  was  five  years  after  the  paper  by  Dr.  Rehwinkel, 
and  when  the  treatment  was  rapidly  slipping  away  from  the 
plans  adopted  by  Dr.  Riggs.  His  operation  for  the  cure  of 
these  conditions  was  very  simple,  and  without  differentiation 
between  the  inflammations  caused  by  deposits  of  salivary  cal- 
culus and  those  in  which  pus  pockets  were  formed.  In  prac- 
tically all  cases  the  operation  was  the  same,  except  as  to  the 
extent  of  cutting  required.  The  gingivae  and  gum  tissue  were 
cut  away  sufficiently  to  remove  all  diseased  tissue  to  the  line  of 
attachment  of  the  peridental  meml)rane.  It  was  usually  neces- 
sary to  cut  away  more  or  less  of  the  uuinflamed  gingivjp  of 
neighboring  teeth  in  order  to  have  a  reasonably  even  line  of 
attachment  aftei*ward.  This  operation  will  often  leave  con- 
siderable of  the  cementum  exposed  when  cases  have  healed. 

It  seems  that  many  of  Dr.  Riggs'  cases  did  well.  In  my 
own  use  of  this  plan  in  some  very  bad  cases  caused  by  deposits 
of  salivary  calculus,  in  which  there  was  a  great  thickening  of 
the  gum  tissue,  I  have  been  surprised  at  the  rapidity  of  recoveiy 
and  the  readiness  with  which  the  soft  tissues  accepted  the  new 
line  of  attachment.  The  treatment  was  })loody,  often  extremely 
so,  but  the  hemorrhage  ceased  promptly  and  was  of  no  conse- 


INVESTING    TISSUES.       DISEASES    AND    TREATMENT.  67 

quence.  Generally  no  medication  was  used,  ^^^atever  else 
Dr.  Riggs  may  have  accomplished,  he  certainly  succeeded  in 
calling  the  attention  of  the  profession  to  the  treatment  of  dis- 
eased gingivae  as  had  been  done  by  no  one  else. 

De.  Rehwinkel's  paper.  Dr.  Rehwinkel's  paper  in  1877  was 
by  far  the  best  writing  upon  this  subject  up  to  that  time.  It 
abounds  in  inquiry  rather  than  in  the  discovery  or  announcement 
of  principles  of  pathology.  It  is  rich  in  references,  and  espe- 
cially in  quotations  from  both  American  and  European  authors. 
Taken  altogether,  it  gives  a  good  view  of  the  opinions  of  men 
regarding  the  diseases  of  the  gingiviP  at  and  before  the  time 
at  which  it  was  written.  Although  it  set  a  landmark  in  the 
name  to  which  it  gave  origin,  it  did  little  to  advance  our  knowl- 
edge of  these  diseases.  A  feature  of  the  paper  that  seems  curi- 
ous to  one  reading  it  now  is  the  fact  that  no  hint  is  given  of  the 
pus  pocket  as  such,  or  as  a  distinct  entity  in  the  patholog^^  of 
the  peridental  membrane.  The  nearest  approach  to  this  idea  is 
the  mention  of  the  peculiar  form  of  calculus  which  occurs  on 
the  sides  of  roots  when  the  membranes  have  been  destroyed. 
He  states  that  this  calculus  is  something  different  from  salivary 
calculus.  In  his  quotations  there  are  many  suppositions  regard- 
ing systemic  conditions  as  causative  factors  in  inducing  disease 
of  this  tissue. 

Gouty  diathesis  as  a  theory.  These  events  occurred  at  a 
time  when  there  was  the  wildest  use  of  antiseptics  in  the  treat- 
ment of  suppurative  conditions  wherever  found,  and  often  with- 
out much  regard  to  other  conditions.  This  may  have  caused 
the  neglect  of  the  study  of  the  pathology  which  is  so  general  in 
the  writings  on  the  su])ject.  It  is  true  that  from  time  to  time 
suggestions  as  to  the  pathology  have  been  advanced.  Many  of 
these  have  been  based  upon  suppositions  regarding  systemic 
causative  influences,  as  a  connection  between  the  gouty  diathesis 
or  uric  acid  dyscrasia  and  pus  pockets  on  the  roots  of  the  teeth. 
Perhaps  an  article*  by  Dr.  Edwin  T.  Darby,  of  Philadelphia,  in 
1892,  gives  the  best  expression  of  this  thought,  which  had  a  wide 
influence  for  a  considerable  time.  The  treatment  for  the  uric 
acid  dyscrasia  seems  to  have  been  tried  out  very  thoroughly  by 
a  number  of  practitioners.  However,  we  may  judge  that  such 
treatment  has  not  been  sufficiently  successful  to  justify  its  con- 
tinuance. Gout  and  rheumatism  are  eminently  nonsupi)urativo 
diseases,   while   diseases   of  the   peridental   iii('inl)raiie  are  as 

*  Dental  Erosion  and  the  Gouty  Diathesis.     Dental  CosTnos,  Vol.  .'Hi,  1892,  p.  (5129. 


68  SPECIAL    DENTAL   PATHOLOGY. 

remarkable  for  their  suppurative  features.  They  stand  wide 
apart. 

In  the  course  of  the  discussions  referred  to  it  was  announced 
by  Dr.  C.  N.  Pierce*  that  he  had  found  calculus  on  the  sides  of 
the  roots  of  teeth  not  before  diseased,  about  which  abscesses 
occurred,  and  that  these  calculi  showed  uric  acid  by  the  murexid 
test.  Very  soon  there  were  other  cases  reported.  It  then  looked 
as  if  we  should  have  to  use  this  test  upon  any  calculus  found  in 
the  mouth  as  a  diagnostic  feature. 

Under  these  conditions  I  undertook  a  bit  of  work  in  this 
line.  I  was  skeptical  regarding  the  finding  of  calculi  on  the 
sides  of  the  roots  of  teeth  as  the  initial  step  in  the  formation 
of  pus  pockets.  The  conditions  causing  lateral  abscesses  had 
been  so  persistently  overlooked  by  others  that  I  felt  free  to 
question  this  statement.  The  peridental  membranes  are  often 
deeply  diseased  with  but  little  showing  superficially.  One  who 
is  not  habitually  examining  the  subgingival  spaces  may  readily 
overlook  the  existence  of  pus  pockets  until  he  is  surprised  by  a 
lateral  abscess. 

I  was  at  the  time  seeing  many  patients  in  various  condi- 
tions of  physical  health;  good,  medium  and  bad.  Some  had 
diseased  gingivae,  some  had  not.  Some  had  rheumatic  or  gouty 
tendencies,  some  had  not.  From  these  I  gathered  calculus  with 
written  records,  made  the  tests,  and  made  a  reportf  in  1894  as 
a  reply  to  the  findings  of  Dr.  Pierce  and  others.  I  found  the 
test  entirely  unreliable  as  showing  a  uric  acid  dyscrasia.  It  was 
occasionally  absent  when  it  should  have  been  present,  and  was 
often  present  when  it  should  have  been  absent.  The  fact  seemed 
to  be  that  the  small  amount  of  uric  acid  present  in  the  blood  in 
normal  conditions  might  give  color  in  salivary  calculus  by  this 
test.    It  was  therefore  useless  as  a  diagnostic  feature. 

Special  infection  theory.  There  has  been  for  many  years 
an  almost  incessant  search  for  some  special  infecting  agent 
which  serves  as  an  initial  cause  of  the  foiTnation  of  pus  pockets, 
and  the  gradual  spreading  of  these  through  the  mouth.  This 
search,  in  which  I  myself  was  active  for  a  long  time,  has  not,  up 
to  the  present  time,  brought  definite  results.  No  complete 
studies  of  the  micro-organisms  normal  to  the  human  mouth 
have  yet  been  well  presented  in   any  book   or  writing.     Dr. 

•  Etiology  of  Pyorrhea  Alveolaria.  International  Dental  Journal,  Vol.  15, 
1894,  p.  1. 

f  "  Diseases  of  the  Peridental  Membranes  and  the  Uric  Acid  Diathesis."  Dental 
Review,  Vol.  8,  1894,  p.  449. 


INVESTING   TISSUES.      DISEASES   AND   TREATMENT.  69 

Miller  and  others  have  isolated  many  species  of  organisms 
from  the  saliva,  but  we  should  know  accurately  what  micro- 
organisms are  normal  to  the  human  saliva,  or  may  always 
be  found  there.  All  others  found  there  will  be  in  the  saliva  by 
accident,  i.  e.,  accidentals.  These  may  or  may  not  be  pathogenic 
varieties. 

Some  years  ago  I  took  up  the  subject  in  this  way.  A  certain 
number  of  plants  were  made  from  each  mouth  and  plated  out. 
Pure  cultures  of  each  organism,  which  would  grow  and  form 
colonies  on  semisolid  media,  were  obtained  and  their  pathogenic 
properties  tested  by  inoculation  of  animals.  The  distinct  forms 
were  listed,  and  divided  into  two  groups;  those  which  were 
normal  or  constant  in  the  saliva  and  those  which  were  acci- 
dentals. In  this  way  I  studied  many  mouths,  trying  to  find  the 
organisms  normal  to  the  saliva,  or  those  present  in  every  mouth 
which  was  well  kept,  and  the  additional  organisms  found  in  a 
series  of  mouths  not  well  kept.  These  investigations  showed 
certain  organisms  constantly  present  in  the  mouths  of  careless 
persons  which  could  not  be  found  in  the  mouths  of  persons  who 
were  careful  as  to  cleanliness.  Many  other  facts  will  appear  in 
such  a  course  of  study  which  will  surprise  most  bacteriologists, 
even  those  who  believe  themselves  well  acquainted  with  the 
flora  of  the  human  saliva. 

About  fifteen  varieties  will  probably  cover  the  organisms 
that  are  constant,  only  about  half  of  which  can  be  cultivated 
upon  the  ordinary  media,  semisolid  or  fluid.  All  of  the  others 
are  accidentals.  In  one  locality  some  of  the  accidentals  may 
persist  for  one  or  two  years,  and  then  disappear.  I  found  one 
organism  constant  in  Chicago  among  both  students  and  infir- 
mary patients,  for  two  years  — 1892  and  1893.  I  had  never  seen 
it  before.  The  third  year  it  had  disappeared  completely.  It 
did  not  occur  in  my  cultures  in  Jacksonville,  111.,  two  hundred 
and  forty  miles  away.  Taking  just  this  small  line  of  facts,  one 
will  see  that  it  is  not  safe  to  rush  into  print  on  such  a  proposi- 
tion. To  try  out  these  organisms  on  animals  as  to  possible 
pathogenic  qualities,  is  in  itself  a  large  undertaking. 

I  found  that,  with  my  practice,  I  could  not  have  the  time  to 
make  this  line  of  work  complete.  It  is  expensive  and  exacting 
as  to  both  space  and  care  to  keep  the  necessary  animals  for 
pathological  tests  in  such  a  way  that  they  will  not  contaminate 
each  other.  We  need  young  men  with  sufficient  financial  support 
to  enable  them  to  do  this  work.  It  is  only  by  such  work  that  we 
will  ever  obtain  that  ])road  view  of  this  subject  which  is  so 


70  SPECIAL   DENTAL   PATHOLOGY. 

desirable.  At  present  we  are  unable  to  definitely  place  any 
organism,  except  the  one  constant  in  the  saliva,  the  staphylo- 
coccus albus,  in  a  causative  relation  to  the  suppurative  features 
of  diseases  of  the  gingivir.  When  the  inflammations  are  begun 
by  traumatisms  of  any  kind,  this  organism  will  keep  up  pus 
formation  as  long  as  there  is  a  pocket  in  which  it  can  remain 
enclosed.  It  is  not  a  virulently  pathogenic  organism.  It  is 
common  to  the  skin  and  is  the  organism  generally  found  in  boils. 
Without  some  break  that  gives  it  an  advantage,  it  will  not  ini- 
tiate a  condition  of  disease  in  the  mouth  or  in  the  skin. 

Serum  treatment.  Serum  for  the  control  of  suppura- 
tions is  being  sought  for  by  many  bacteriologists  and  other 
researchers.  As  a  general  principle  it  would  seem  that  any 
infection  which  is  self-limiting  should  be  controllable  by  an 
immunizing  serum.  This  is  in  accord  with  the  theory  that  the 
poison  eliminated  by  the  causative  organism  arouses  the  forma- 
tion of  an  antibody  by  the  tissues  themselves,  which  destroys 
the  effect  of  the  micro-organism.  Such  a  serum  may  be 
employed  to  estalilish  immunity,  or  it  may  be  administered  soon 
after  exposure  or  at  tlie  beginning  of  an  attack,  and  either  pre- 
vent the  attack  entirely  or  materially  moderate  it.  In  this 
group  of  diseases  a  more  or  less  permanent  immunity  is  estab- 
lished by  the  use  of  serum. 

In  the  use  of  serums  to  control  suppurations,  it  is  not 
expected  that  immunity  will  be  established.  The  patient  may 
be  cured  of  the  particular  attack,  but  there  will  be  no  lasting 
effect  against  another  similar  attack.  Many  cases  of  peridental 
disease  have  been  reported  as  much  improved  by  the  use  of 
serums,  the  same  as  pyogenic  infections  in  other  parts  have  been 
benefited.  There  has,  however,  been  no  cure  of  the  pus  pocket 
by  such  treatment,  even  though  the  discharge  of  pus  might  have 
been  temporarily  stopped.  The  denuded  cementum  has  remained 
as  a  continuously  acting  irritant,  and  as  soon  as  the  effect  of  the 
serum  has  passed,  conditions  are  favorable  for  the  re-establish- 
ment of  the  infection  and  pus  formation. 

Regardless  of  the  success  of  this  and  other  methods  of 
treating  suppurative  infections  up  to  the  present  time,  or  of 
the  further  progress  of  this,  work  in  the  future,  it  does  not 
appear  to-day  as  though  we  can  hope  for  relief  in  the  applica- 
tion of  these  methods  to  the  pus  pocket  alongside  of  a  root,  for 
the  reason  mentioned  above,  that  we  are  unable  to  remove  the 
continuous  irritant. 


INVESTING    TISSUES.      DISEASES    AND    TREATMENT.  71 

The  TREATMENT  IN  VOGUE.  All  of  this  lias  had  but  little 
influence  in  shaping  the  general  treatment  now  in  use  for  chronic 
suppurating  pockets.  The  treatment  generally  in  vogue  has  con- 
sisted of  the  removal  of  deposits  of  serumal  calculus  which  were 
found  adhering  to  the  cementum  where  the  soft  tissues  had  been 
parted  from  it,  and  the  use  of  antiseptics  in  an  effort  to  control 
the  discharge  of  pus.  The  supposition  was  that  the  soft  tissues 
would  become  reattached  to  the  cementum  if  they  had  a  favor- 
able opportunity.  This,  it  was  thought,  would  bring  about  a 
cure  of  the  condition.  This  is  a  succinct  statement  of  the  prac- 
tice now  most  generally  employed  in  pus-pocket  conditions. 

Has  this  treatment  proved  satisfactory?  Have  cases  pre- 
senting deep  pus  pockets  on  the  sides  of  the  roots  of  teeth 
healed  and  remained  well  afterward  under  reasonable  care  by 
the  patient?  In  this,  it  is  not  a  question  whether  cases  come  to 
look  better  and  to  show  less  flow  of  pus  under  this  treatment,  but 
do  they  really  get  well  with  a  reasonably  good  reattachment  of 
the  soft  tissues  to  the  cementum  ? 

I  have  had  a  long  and  very  careful  observation  of  this  treat- 
ment, both  in  my  own  practice  and  in  the  examination  of  patients 
who  have  been  under  treatment  by  others.  I  have  found  much 
improvement  in  general  conditions  of  the  gingivae  as  examined 
by  the  eye.  I  have  seen  cases  which  had  been  bad,  with  much 
pus  issuing,  improve  so  that  no  pus  was  apparent.  Such  have 
been  common  in  my  own  practice,  and  I  am  sure  this  is  true  in 
the  practice  of  others  also.  However,  a  careful  examination  with 
the  subgingival  explorer  showed  that  the  pockets  had  not  closed, 
and  subsequent  observation  revealed  the  fact  that  the  tissues 
of  the  gingivae  had  not  maintained  a  healthful  tone. 

I  have  myself  kept  patients  on  and  on  in  this  condition,  all 
of  the  time  having  them  make  frequent  visits  for  inspection  and 
direction  as  to  cleaning,  all  of  the  time  making  frequent  use  of 
antiseptics.  These  cases  have  apparently  done  fairly  well  in  the 
main,  but  have  never  really  gotten  well  by  reattachment  of 
the  tissues  to  the  cementum.  Some  of  them  would  show  only 
occasionally  an  acute  inflanmiation  ahout  some  particular  tooth, 
or  teeth,  which  passed  away,  leaving  the  pocket  deeper  than 
before.    In  this  slow  way  the  cases  became  worse. 

In  some  of  the  cases  I  placed  the  loose  teeth  in  bands  con- 
nected with  other  teeth  to  hold  the  looser  ones  steady.  As  the 
roots  became  more  and  more  difficult  to  keep  clean,  on  account 
of  the  broadening  of  the  already  wide  pockets,  I  cut  off  and 


72  SPECIAL   DENTAL    PATHOLOGY. 

removed  the  roots,  leaving  the  crowns  in  the  gold  bands  to  serve 
the  purpose  of  mastication.  This  was  certainly  pushing  the 
preservation  of  the  natural  teeth  to  the  limit,  and  I  came  to  so 
regard  it.  I  have  since  had  reason  to  believe  that  I  went  much 
too  far  in  my  effort  to  cure.  Much  too  large  a  percentage  of 
those  people  are  dead.  As  it  was  with  my  patients,  I  believe  it 
has  been  with  patients  of  others.  After  the  use  of  the  forceps  I 
have  seen  many  of  these  sallow,  not  much  sick  but  complaining 
persons,  brighten  up  and  again  enjoy  life. 


STUDIES    OF    SALIVARY    CALCULUS,  73 


STUDIES  OF  SALIVARY  CALCULUS 

ILLUSTRATIONS:    FIGURES  122-143. 

Salivary  calculus  is  the  term  applied  to  the  calculus  which 
enters  the  mouth  with  the  saliva,  and  becomes  deposited  upon 
the  teeth,  plates,  or  other  hard  substances  within  the  mouth. 
The  word  salivary  is  used  to  distinguish  this  deposit  from  the 
calculus  which  may  be  deposited  in  the  gall  bladder,  urinary 
bladder  and  elsewhere.  Since  other  calculi  found  in  the  body 
are  very  closely  related,  the  gall  bladder  calculi  being  formed 
of  cholestrimi  instead  of  calcium  salts,  and  since  the  underlying 
causes  of  all  are  probably  similar,  the  investigations  here  pre- 
sented apply  in  large  measure  to  all  of  the  various  forms  of 
calculi.  In  fact,  it  will  be  shown  that  there  is  little  question  to 
doubt  but  that  the  elements  necessary  to  the  formation  of  the 
deposit  in  all  the  various  places  in  which  it  may  occur  are  pres- 
ent in  all  simultaneously  and  lack  only  the  local  nidus  which  is 
necessary  to  a  beginning  accumulation. 

Composition. 

Salivary  calculus  is  composed  of  calcium  phosphate,  with 
the  addition  of  smaller  amounts  of  calcium  carbonate,  held 
together  in  mass  by  an  organic  compound  which,  according  to 
general  opinion,  is  formed  after  the  material  has  been  deposited 
upon  the  teeth,  natural  or  artificial.  The  fresh  deposit  is  very 
soft  and  greasy  to  the  feel  of  the  fingers,  insoluble  in  water,  in 
alcohol  and  most  fluids  that  one  would  be  likely  to  tiy.  This 
mass  I  have  called  agglutinin,  or  agglutinin  of  calculus.  When 
it  is  deposited  upon  a  plate,  or  upon  the  teeth,  it  may  readily  be 
washed  away  and  the  plate  or  the  teeth  perfectly  cleaned  with 
an  ordinary  brush  and  water.  This,  however,  must  be  done 
within  five  to  twelve  hours  after  the  material  has  been  deposited, 
if  it  is  to  be  removed  easily.  If  one  waits  twenty-four  hours  it 
has  begun  to  harden  and  it  is  difficult  to  remove  with  the  brush. 
If  one  waits  for  several  days  or  a  week,  it  can  not  be  brushed 
away.  It  continues  to  increase  in  hardness  for  one  or  two 
months,  and  at  the  end  of  this  time  is  fully  hard.  When  it  has 
become  hard,  instruments  are  required  to  break  or  to  scrape  it 
awav. 


74  SPECIAL   DENTAL   PATHOLOGY. 

The  deposit  does  not  occur  in  every  month.  In  some 
mouths,  there  will  be  an  occasional  deposit,  with  long  periods 
during  which  there  is  none.  In  others  the  deposit  seems  to  be 
occurring  all  the  time.  Generally  children  and  young  people 
are  freer  from  deposits  of  calculus  than  adults.  Quite  a  number 
of  cases  occur  in  which  persons  have  no  deposits  until  they  are 
forty,  fifty  or  even  sixty  years  old,  and  afterward  are  much 
troubled  with  it.  These  may  be  said  to  be  general  conditions 
noted  by  every  dentist  who  is  a  good  observer  and  has  had  many 
years  of  practice.  It  gives  the  idea  that  there  is  a  systemic 
dyscrasia  which  is  responsible  for  these  deposits. 

Analysis.  In  the  text-books,  a  number  of  analyses  of  sali- 
vary calculus  have  been  published.  These  differ  considerably. 
A  part  of  these  differences  are  due  to  variations  in  the  amount 
of  water  and  mucus,  and  the  fact  that  a  number  of  them  combine 
water  and  organic  substances  in  their  report.  One  may  analyze 
calculus  fresh  from  the  mouth,  only  drying  it  upon  blotting 
paper.  Another  may  have  analyzed  calculus  that  was  old  and 
thoroughly  dry.  Unless  these  conditions  are  stated,  the  amount 
of  water  will  vitiate  the  figures  of  the  whole  analysis.  I  give 
here  an  analysis  by  Scliehevetskey*  which  gives  as  good  an  idea 
of  its  composition  as  can  be  obtained  from  these  analyses.  Such 
reports  would  naturally  vary,  for  I  do  not  suppose  calculus  is 
a  strict  chemical  compound  of  invariable  composition. 

Water  and  organic  matter 22.07 

Magnesium  Phosphate 1 .  07 

Calcium  Phosphate 67 .  18 

Calcium  Carbonate 8.13 

Calcium  Fluoride   1 .  55 


100.00 
In  a  number  of  the  analyses  no  magnesium  phosphate  is 
reported ;  in  some  a  little  calcium  fluoride  is  reported. 

STUDIES    OF    DEPOSIT    OF    SALIVARY    CALCULUS. 

Considering  the  length  of  time  in  which  the  deposit  of 
salivary  calculus  and  the  great  injury  it  has  done  to  mankind 
have  been  observed,  the  history  of  the  study  of  it  in  the  literature 

*  Burchard  on  "The  Orifjin  of  Salivary  Calculus,"  Dental  Cosmos,  1895,  p.  821. 
Also  see  Burchard's  Dental  Pathology,  edition  of  1898.  A  considerable  number  of 
these  analyses  are  very  old,  and  may  be  traced  from  book  to  book  from  away  bat-k 
to  the  first  half  of  the  last  century,  or  even  earlier.  I  have  noted  in  a  few  of  thorn 
that  errors  in  transcribing  have  occurred,  and  have  been  carried  on  from  one  bonk  to 
another. 


STUDIES    OF    SALIVARY    CALCULUS.  75 

is  very  disappointing.  Until  quite  recently  it  would  seem  that 
no  successful  effort  has  been  made  to  penetrate  this  mystery. 
All,  or  nearly  all,  have  agreed  upon  certain  points  and  there 
the  subject  has  been  dropped.  The  essential  facts  in  the  writ- 
ings of  many  men  may  be  covered  in  a  few  sentences. 

The  points  on  which  most  men  have  agreed  have  been  these : 
Calculus  is  composed  mostly  of  calcium  salts  which  are  pre- 
cipitated from  the  saliva.  These  salts  find  lodgment  and  settle 
in  out-of-the-way  places  about  the  teeth,  and  become  aggregated 
by  entanglement  in  partly  inspissated  mucus  or  other  colloids 
from  the  saliva.  In  these  positions  the  material  settles  into 
more  compact  form,  as  the  colloid  material  is  slowly  decom- 
posed, and  hardens  into  stone-like  masses.  These  masses  grow 
by  more  or  less  constant  additions  upon  the  hardened  or  harden- 
ing material,  until,  sometimes,  quite  large  and  thick  masses  of 
it  are  fonned.  These  masses  are  in  part  in  contact  with  the 
soft  tissue  investments  of  the  teeth,  and  cause  them  to  become 
inflamed  and  to  be  destroyed  partly  by  absorption  and  partly 
by  suppuration,  resulting  in  the  loosening  and  final  loss  of  the 
teeth. 

Among  the  writers  much  difference  of  phraseology  may  be 
observed,  but  the  whole  subject  is  practically  included  in  the 
above  statement.  The  late  Dr.  A.  W.  Harlan  was  to  prepare  a 
paper  on  salivar^^  calculus  for  the  American  System  of  Den- 
tistry which  was  published  in  1886.  In  a  conversation  regard- 
ing this  paper  he  stated  that  there  was  little  to  write,  as  the 
subject  really  had  no  literature,  and  nothing  was  positively 
known  about  it.  He  finally  offered  an  article  which  is  printed 
in  the  second  volume,  page  273  of  that  work,  consisting  of  nine- 
teen pages.  Four  of  these  are  taken  up  in  quotations  from 
thirteen  different  authors,  two  to  a  discussion  of  green  stains 
on  teeth  and  the  remaining  pages  to  the  removal  of  calculus 
from  the  teeth.  This  statement  strikes  me  as  the  most  graphic 
representation  of  the  little  that  iras  known  of  the  subject  up  to 
that  time,  that  I  could  now  write. 

Dr.  Burchard's  studies.  Since  the  publication  of  the  Amer- 
ican System  of  Dentistry,  further  efforts  have  been  made  to 
advance  our  knowledge  of  this  sul)ject.  The  most  notable  of 
these  will  be  found  in  Dr.  Henry  H.  Burchard's  article*  on  "Tlie 
Origin  of  Salivary  Calculus"  in  1805,  and  in  his  bookf  published 
in  1898.    In  a  second  edition  of  the  book,  since  Dr.  Burcliard's 


*  Dental  Cosmos,  Vol.  37,  1895,  p.  821. 

t  Dental  Pathology  and  Therapeutics,  1898,  p.  447. 


76  SPECIAL    DENTAL   PATHOLOGY. 

death,  his  ideas  have  not  been  veiy  closely  followed.  From  the 
frequent  references  to  assistance  and  support  by  Dr.  E.  C.  Kirk, 
of  Philadelphia,  it  would  seem  that  he  had  Dr.  Kirk's  assistance 
in  the  development  of  his  subject,  especially  in  the  preparation 
for,  and  the  carrjang  forward  of,  the  experimental  work,  the 
results  of  which  form  the  basis  of  the  presentation  in  both  the 
journal  article  and  in  the  book. 

In  order  to  fully  comprehend  a  short  resume  of  this  work 
and  its  conclusions,  one  should  have  in  mind  the  following  well- 
known  facts:  Carbon  dioxid  dissolves  in  water  or  fluids  con- 
taining water.  When  a  fluid  contains  this  gas  in  solution,  its 
power  of  dissolving  certain  salts  is  markedly  increased.  The 
excess  of  salts  thus  dissolved  above  saturation  without  the  car- 
bon dioxid,  will  be  precipitated  if  the  carbon  dioxid  is  removed. 
If  the  pressure  of  the  atmosphere  is  increased  —  as  by  pumping 
carbon  dioxid  into  a  closed  space  with  an  air  pump  —  the  amount 
of  carbon  dioxid  dissolved  in  the  liquid  is  increased  and  its 
power  of  holding  salts  in  solution  is  increased  in  a  similar  pro- 
portion. If  now  the  pressure  which  holds  the  carbon  dioxid  in 
solution  is  relieved  and  the  extra  portion  of  carbon  dioxid 
allowed  to  escape,  the  extra  proportion  of  a  salt  dissolved  under 
pressure  will  be  precipitated. 

In  the  animal  body  carbon  dioxid  is  continually  being  formed 
by  tissue  metabolism  and  eliminated,  mostly  by  the  lungs,  but 
always  leaving  a  residue  in  the  tissues  and  body  juices.  There- 
fore, all  of  the  fluids  of  the  body  are,  in  a  degree,  charged  with 
carbon  dioxid,  and  its  power  of  holding  salts  in  solution  is  influ- 
enced to  some  extent  by  the  blood  pressure.  Therefore,  these 
fluids,  as  well  as  the  secretions  and  excretions  derived  from  them, 
may  have  a  little  more  carbon  dioxid  and  a  little  more  calcium 
salts  in  solution  than  they  will  retain  after  removal  of  this 
blood  pressure,  which  they  lose  when  secretions  which  contain 
them  are  exposed  to  the  air.  In  such  a  case  the  extra  amount  of 
calcium  salts  in  solution,  if  there  be  any  in  excess  of  ordinary 
saturation,  will  be  precipitated.  It  is  only  by  experimental 
results  that  we  can  know  whether  such  an  excess  exists  in  any 
particular  secretion. 

The  propositions  made  by  Dr.  Burchard  are  reducible  to 
two,  around  which  the  whole  experimentation  and  argument 
hinges.    These  are: 

1.  Saliva  contains  calcium  ])hosphate  and  other  salts  in 
solution,  held  ]»y  dissolved  carbon  dioxid.    When  delivered  into 


STUDIES    OF    SALIVAEY    CALCULUS.  77 

the  mouth,  the  normal  pressure  on  the  body  juices  is  relieved, 
the  carbon  dioxid  escapes  and  a  portion  of  the  calcium  phosphate 
and  the  other  salts  is  precipitated. 

2.  Mucus  is  a  normal  constituent  of  saliva.  Lactic  acid  is 
being  continuously  formed  in  the  mouth  by  certain  micro- 
organisms. Lactic  acid  converts  mucus  into  a  curd  in  which  the 
precipitate  of  calcium  and  other  salts  becomes  entangled,  and 
this  hardens  in  the  form  of  salivary  calculus. 

These  statements  agree  with  the  views  generally  held  as  to 
the  nature  of  these  deposits. 

In  the  experimental  work  reported,  it  was  found  that  freshly 
collected  saliva  cleared  by  filtering,*  or  otherwise,  and  placed  in 
an  open  test-tube,  will  have  become  cloudy  the  next  day.  The 
interpretation  was  that  the  saliva,  known  to  contain  calcium 
salts  in  solution,  slowly  lost  its  carbon  dioxid  and  the  excess  of 
calcium  salts  was  precipitated  and  formed  the  cloud. 

Another  strong  feature  of  Dr.  Burchard's  experimentation 
I  may  fairly  express  in  this  way.  The  mixed  saliva  contains  a 
considerable  proportion  of  mucus  as  a  normal  constituent.  Tliis 
mucus  is  precipitated  by  lactic  acid  in  the  form  of  a  curd,  which 
rises  to  the  surface,  the  amount  and  strength  of  which  will  be  in 
close  relation  to  the  strength  of  lactic  acid  used.  This  curd  may 
be  seen  when  a  few  drops  of  one  per  cent  lactic  acid  are  dropped 
into  a  test-tube  of  freshly  drawn  and  cleared  saliva.  A  much 
stronger  curd  is  formed  by  a  few  drops  of  ten  per  cent  lactic 
acid.  The  saliva  of  different  persons  and  of  the  same  person  at 
different  times  contains  a  variable  amount  of  mucus,  and  the 
amount  of  this  curd  will  also  depend  upon  the  amount  of  mucus 
in  a  particular  specimen  of  saliva,  as  well  as  the  percentage  of 
lactic  acid  added.  The  supposition  expressed  is,  that  the  pre- 
cipitate of  calcium  salts,  falling  out  of  solution,  becomes 
entangled  in  the  slight  curds  of  mucus  fonning  in  undisturbed 
places  about  the  mouth.  These  become  harder  and  stronger, 
forming  salivary  calculus,  which  grows  very  slowly  ])ut  in  time 
foraas  solid,  stone-like  masses.  These  are  in  positions  in  wliich 
they  can  slowly  settle  without  too  much  disturbance  from  the 
movements  of  the  tongue  and  the  buccal  and  labial  mucous  mem- 
branes, as  along  the  crests  of  the  free  gingiva?,  especially  in 
places  where  there  is  a  slight  thickening  of  the  crest,  which  will 
afford  a  little  protection  against  the  rubbing  of  tlie  tissues  and 

*  In  the  filtering  of  saliva  much  of  the  colloids  remain  on  the  filter,  changing  the 
composition  in  that  degree.  This  is  avoided  by  clearing  veitli  the  centrifuge,  or  by 
allowing  the  saliva  to  stnnd  until  it  settles. 


78  SPECIAL   DENTAL   PATHOLOGY. 

of  the  food  which  is  eaten.  This  idea  is  in  some  difficult^^  to 
account  for  the  almost  universal  observation  that  the  first  and 
greatest  deposit  of  calculus  occurs  on  the  teeth  nearest  to  the 
ducts  of  tlie  salivary  glands. 

The  papers  mentioned  are  well  written  and  their  appear- 
ance marked  a  new  era  in  the  study  of  this  subject.  Since  their 
publication  they  seem  to  have  served  as  the  basis  of  thought  for 
other  writers. 

I  will  show  in  the  next  few  pages,  however,  that  the  cloud 
formed  in  the  test-tube,  supposedly  calcium  salts  precipitated 
with  the  release  of  carbon  dioxid,  was  not  calcium  salts  but  a 
growth  of  micro-organisms,  and  that  salivary  calculus  is 
deposited  in  a  substratum  of  globulin  and  not  in  a  coagulated 
mucus ;  that  a  very  considerable  deposit  may  occur  near  the 
salivarj^  ducts  within  a  few  hours  instead  of  this  slow  settling- 
down  in  the  out-of-the-way  places,  etc.  Again,  lactic  acid,  which 
is  added  to  saliva  in  a  ten  per  cent  solution  in  order  to  form  a 
strong  curd  —  as  expressed  in  Dr.  Burchard's  account  of  his 
experimentation  —  would  convert  a  precipitate  of  calcium  phos- 
phate into  a  highly  soluble  lactate,  which  would  be  carried  away 
in  the  oral  fluids  instead  of  forming  a  hard  concretion. 

Again,  the  formation  of  what  I  originally  called  the  gela- 
tinuous  plaque,  gelatinoid  plaque,  etc.  (always  avoiding  a 
strictly  chemical  term,  of  which  I  was  uncertain),  has  appar- 
ently been  found  to  be  by  the  coagulation  of  mucin  into  a  film 
or  mass  by  lactic  acid.*  This  is  developed  by  the  growth  of  a 
colony  of  micro-organisms  occupying  a  sheltered  position,  and 
which  is  more  perfectly  covered  in  by  this  film.  This  condition 
prevents  the  acid  formed  by  the  organisms  from  being  dissi- 
pated in  the  general  saliva.  The  result  is  a  solution  of  the  cal- 
cium salts  of  the  enamel,  forming  caries  of  the  enamel.  Hence, 
we  see  that  the  scene  of  the  coagulation  of  mucin  by  lactic  acid, 
is  that  of  a  solution  and  conversion  of  the  less  soluble  phos- 
phates into  the  more  soluble  lactates.  This  was  well  shown  by 
Dr.  W.  D.  Miller  in  his  original  experiments,  by  which  he  deter- 
mined the  phenomena  of  caries  of  dentin  (Ajnerican  System 
of  Dentistry,  Vol.  1,  p.  791).  This  again  shows  definitely  that 
a  coagulum  of  mucin  by  lactic  acid  would  not  become  the  scene 
of  the  entanglement  of  precipitated  particles  of  calcium  salts  for 
the  formation  of  the  hard  concretions,  such  as  salivary  calculus. 


*  "  Some  Conclusions  Growing  Out  of  a  Study  of  the  Cause  of  Dental  Caries," 
by  Charles  E.  Jones,  Dental  Review,  1911,  p.  1167. 


STUDIES   OF    SALIVARY    CALCULUS.  79 

Therefore,  it  seemed  necessary  that  we  find  some  other  explana- 
tion of  the  formation  of  salivary  calculus. 

Personal  Investigations  of  the  Deposit  of  Salivary  Calculus. 

The  following  report  of  my  investigations  of  the  deposit  of 
salivary  calculus  is  written  after  about  five  years  of  experi- 
mental work.  Naturally  many  experiments  were  pursued  with 
results  which  were  of  little  or  no  value,  others  failed  from  one 
cause  or  another.  For  this  writing  I  have  selected  and  reported 
only  those  which  have  added  something  to  our  knowledge  of 
the  subject.  These  are  presented  in  what  seems  now  to  be  the 
most  logical  order,  without  regard  for  the  order  in  which  they 
were  actually  made. 

During  these  investigations  I  have  written  two  articles  in 
which  the  knowledge  of  this  subject  developed  at  the  time  of 
writing  was  presented.  The  first  of  these,  entitled  **  Beginnings 
of  Pyorrhea  Alveolaris  —  Treatment  for  Prevention,  etc., ' '  was 
published  in  the  Items  of  Interest,  Vol.  33,  1911,  p.  420.  The 
second,  entitled  ''Deposit  of  Salivary  Calculus,"  was  published 
in  the  Dental  Review,  Vol.  26,  1912,  p.  337. 

A  special  machine  was  designed  and  built  for  the  purpose 
of  grinding  microscopic  specimens  of  hard  substances,  such  as 
deposits  of  calculus,  teeth,  etc.  This  machine  is  described  at  the 
end  of  the  book,  and  is  illustrated  in  Figures  508  to  518. 

As  a  basis  for  my  experimental  work,  I  duplicated  the  work 
reported  by  Dr.  Burchard.  I  made  the  same  experiments  in 
filtering  freshly  collected  saliva  and  observed  the  cloud  which 
was  present  in  the  test-tube  the  next  day  —  the  cloud  which  had 
been  interpreted  to  be  composed  of  calcium  salts  precipitated 
by  the  gradual  loss  of  carbon  dioxid  from  the  solution.  It 
occurred  to  me  that  this  experiment  was  unfinished;  it  had  not 
been  proven  that  the  precipitate  was  calcium  salts. 

Test  of  saliva  for  precipitate  of  calcium  salts. 

I  devised  an  instrument  by  bending  a  small  wire  in  a  loop 
and  then  twisting  one  of  the  ends  around  the  other  for  a  suffi- 
cient length  to  reach  nearly  to  the  bottom  of  the  test-tube.  '^Flie 
ends  of  the  wire  near  the  bottom  of  the  tube  were  converted  into 
a  spring  clutch,  into  which  I  placed  a  cover-glass  which  would 
nearly  fill  the  inner  circumference  of  the  tube,  in  a  horizontal 
position.  This  was  let  down  through  the  clouded  portion  to 
within  a  half-inch  of  the  sedimont  wliich  had  collected  in  clearing 
the  saliva,  without  disturbing  it.    I  tlicii  phiccd  this  test-tube  in 


80  SPECIAL   DENTAL,   PATHOLOGY. 

the  electric  centrifuge,  and  allowed  the  machine  to  run  fifteen 
minutes.  On  examination  through  the  test-tube  I  found  the 
liquid  above  the  cover-glass  clear  and  a  film  on  the  cover-glass. 
The  fluid  was  now  drawn  away  as  far  as  the  cover-glass  with  a 
pipette,  so  cautiously  as  not  to  disturb  the  film.  Then  the  cover- 
glass  was  lifted  out.  When  this  was  brought  under  the  lens  of 
the  microscope,  it  did  not  show  a  precipitate  of  calcium  salts. 
The  cover-glass  had  on  it  a  film  of  micro-organisms.  This  result 
occurred  in  every  effort  to  prove  the  findings  related.  I  have 
not  yet  been  able  to  find  the  least  trace  of  precipitated  calcium 
salts,  though  I  have  made  many  efforts.  I  had  previously  fully 
believed  that  such  a  precipitate  did  occur  and  the  results 
obtained  were  disappointing. 

Examination  or  deposits  on  artificial  denture. 

My  recent  studies  of  the  deposit  of  salivary  calculus  were 
undertaken  soon  after  I  began  wearing  a  full  upper  plate,  a 
little  more  than  five  years  ago.  My  first  plate  presented  the 
opportunity  to  observe  the  deposit  of  salivary  calculus  which  I 
occasionally  found  upon  it.  After  a  time,  I  found  some  features 
which  had  never  before  been  presented.  I  then  began  a  sys- 
tematized study  of  the  conditions  under  which  deposits  occurred. 
At  first  this  consisted  of  a  record  of  the  appearance  of  calculus 
in  soft  form  upon  the  plate.  In  pursuing  this,  I  soon  discovered 
that  the  mucous  coating  which  covered  the  plate  and  made  it 
slippery  to  the  fingers,  could  be  washed  away  by  placing  the 
plate  in  still  water  for  a  time,  or  in  running  water,  as  a  jet  from 
the  ordinary  hydrant,  without  disturbing  the  freshest  and  soft- 
est deposit  of  calculus.  The  following  then  became  the  mode 
of  examination:  After  each  meal  the  plate  was  laid  under  the 
hydrant  and  the  water  turned  on  it  for  a  few  minutes,  removing 
the  mucus.  It  was  then  examined  for  deposits  of  calculus. 
These  were  found  only  occasionally.  Sometimes  two  to  four 
weeks,  or  a  longer  time,  would  pass  without  any  deposit  what- 
ever. Then  suddenly  a  heavy  deposit  occurred.  After  the  wash- 
ing with  running  water,  and  the  examination,  the  plate  was 
always  made  clean  in  every  part.  The  deposit  seemed  absolutely 
insoluble  in  running  water,  hot  or  cold,  yet  it  was  so  soft  that 
it  was  readily  cleaned  away  with  a  brush  and  water.  Nothing 
more  was  needed. 

Generally  the  deposit  was  divisible  into  three  zones :  a  cen- 
tral greyish-white  zone,  an  intermediate  semitransparent  zone 
and  an  outer  transparent  zone.    The  whole  deposit  felt  greasy 


Fig.  122. 


Fm.  12:5 


Fig.  122.  A  device  attached  to  a  plate  for  artificial  teeth,  used  for  the  collection 
of  specimens  deposited  directly  on  a  piece  of  the  usual  cover-glass  for  microscopic 
objects.  It  consists  of  a  frame  of  No.  20  gold  plate  fastened  to  tlie  plate  with  a  gold 
screw  at  each  end.  All  of  the  central  part  is  cut  away,  as  shown.  The  vulcanite  has 
been  cut  Hat  over  the  area  covered  by  the  frame,  and  above  and  below  ledges  are 
left  which  will  prevent,  a  glass  cut  to  fit  the  space  slipping  out  in  those  directions. 
The  screws  keep  it  from  slipping  out  endwise.  The  cover-glass  is  laid  in  the  space, 
the  frame  is  laid  upon  it,  and  screwed  do\vn.  This  exposes  all  of  the  central  i)art  of 
the  cover-glass  for  the  collection  of  films.  When  a  film  has  been  dei)osit('d  on  the 
glass  while  being  worn  in  the  mouth,  the  screws  are  removed,  the  franu'  lifted  oil', 
and  the  cover-glass,  with  the  film  undisturbed,  is  removed  and  transferred  tu  the 
li(|uids  ])repar{!d  for  the  staining  process.  A  similar  device  may  lie  attached  to  tin- 
natural  teeth  in  such  a  way  as  to  be  removable. 

Fig.  12.3.  Photomicrograph  of  agglutinin  of  salivary  calculus  moderately  well 
filled  with  calcium  salts,  but  very  soft.  Jt  was  jiressed  down  iimler  a  cover-glass  in 
a  thick  solution  of  sludlac  in  alcohol,  after  thirty  minutes  in  alcohol  to  icinove  water. 
The  general  appearance  of  spherides  is  fairly  well  sec^n. 

Figures  122  to  134  and  Figures  138  and  139  were  originally  publislied  in  the 
Items  of  Interest,  illustrating  a  pajier  entitled:  "  Beginnings  of  rvorrlie;i  Alveolaris, 
Treatment  for  Prevention,  elc,"  Vol.  'M,  I!M1,  p.  -120. 

*» 


Fig.  126. 

Figs.  124,  12.'5,  126.  Agglutinin  of  salivary  calculus  showing  irregular  spherules 
laid  flown  on  cover-glasses  worn  in  the  mouth.  Eosin  stain  with  formalin  as  a  mor- 
dant.    The  stain  is  diffuse. 

In  this  deposit  the  thickest  spherules  show  darkest.  The  finer  spherules,  of 
which  these  are  made  up,  arc  not  distinguishable  in  the  pictures.  The  tendency  to 
form  larger  spherules  by  the  combination  of  smaller  ones  is  apparent,  but  presents  the 
utmost  irregularity  in   the  different  specimens. 

Note. —  The  beginning  of  the  deposit  always  occurs  in  the  little  angle  formed 
by  the  frame  and  the  cover-glass  (see  Figure  122),  and  grows  out  upon  the  glass 
from  that  beginning.  The  cover  glass  has  generally  been  removed  before  being 
completely  covered,  in  order  to  have  thin  margins.  All  the  specimens  are  so  placed 
that  that  portion  next  to  the  frame  is  down  in  the  illustration. 


Fig.  127. 


Fig.  128 

Fig.  127.  Ground  section  of  hard  salivary  calculus  i/^  of  Viooo  '"^'*  thick,  show- 
in{T  sphcmlos  in  thn  upper  part  of  the  field.  While  these  spherule  forma  arc  hard 
ciilenhiH,  that  portion  has  not  received  as  niucii  calcium  salts  as  it  would  have  con- 
tained later.  The  splierules  finally  become  almost  completely  obscuretl,  as  seen  in  the 
lower  portion  of  the  illustration. 

Fig.  128.  Photomicroffraph  from  a  section  of  a  crumb  of  very  black  scrumal 
calculus.  (Sec  descriiition  of  this  process  of  jjrindiny  in  the  Appendix.)  The  outer 
surface  is  the  lower  border  of  tiie  picture,  upon  which  accretion  was  in  progress. 
It  gives  a  slight  showing  of  spherules.     The  irrf«,'uhir  veining  siiows  lines  of  accretion. 


Fig.  129. 


Fig.  13U. 


Fig.  129.  A  stain  by  nigrosiii  following  pliciiol.  Certain  of  the  spherules  do 
not  stain  at  all;  otherwise  the  stain  is  diflfiisive.  A  number  of  light-colored  circles 
will  be  seen  in  the  upper  part  of  the  field,  which  are  unstained  spherule.s,  with  a 
collection  of  fine  granules  about  them  that  take  the  stain  poorly.  Many  of  these  white 
spherules  ajipear  in  the  tiiicker  portions  partially  covered  with  spherules  that  stain. 
Therefore  their  outlines  aj)pear  irregular.  Many  of  these  peep  through  the  thicker 
portions  as  white  points. 

Fig.  130.  Appearance  of  a  rapid  deposit  (about  four  hours),  stained  by  nigrosin 
after  treatment  by  formalin  as  a  mordant.  So  far  as  the  stain  goes  it  is  diffusive,  but 
many  of  the  primar}-^  spherules  refuse  the  stain,  which  gives  a   lobulated  appearance. 


STUDIES    OF    SALIVARY    CALCULUS.  81 

and  sticky  to  the  fingers.  It  was  coagulated  and  whitened  by 
boiling  water  in  a  similar  way  as  is  white  of  an  egg  —  egg  albu- 
men. Phenol  or  alcohol  produced  a  similar  effect.  Therefore, 
if  this  material  is  not  albumen,  it  is  something  closely  approach- 
ing it  in  chemical  composition  and  reaction  to  coagulating 
agents.  It  seems  clear  that  it  is  not  coagulated  mucin,  or  the 
settling  of  a  precipitate  from  the  saliva,  like  that  in  the  teakettle 
in  which  hard  water  is  boiled,  as  taught  by  Burchard. 

Collection  of  deposit  on  cover-glass. 

While  my  series  of  observations  on  conditions  of  deposit 
were  continued,  I  made  every  effort  to  find  means  of  displaying 
the  stinicture  to  better  advantage.  Finally  the  idea  that  I  might 
construct  a  trap  by  which  I  could  catch  the  mass  on  a  cover- 
glass,  suggested  itself,  and  was  quickly  carried  out. 

This  trap  consists  of  a  little  frame  of  gold  plate  fastened 
at  either  end  with  a  screw,  under  which  a  cover-glass  may  be  laid. 
(See  Figure  122.)  A  space  for  it  on  the  plate  is  cut  flat,  leaving 
square  shoulders  at  either  side  to  prevent  the  cover-glass  from 
slipping  out.  The  trap  is  depressed  a  little  below  the  general 
level  of  the  surface  of  the  plate,  in  order  that  deposits  on  the 
glass  will  be  less  likely  to  be  disturbed.  The  traps  which  I  have 
used  take  in  a  cover-glass  five-eighths  by  five-sixteenths  of  an 
inch.  They  may,  however,  be  made  of  any  size  or  form.  At  first 
cover-glasses  were  altered  by  grinding  them  on  the  emery-stone 
to  fit  the  space,  but  later  a  dealer  cut  the  special  form  for  me. 

A  trap  may  be  securely  attached  to  one  or  two  natural 
teeth  in  easily  removable  form.  It  has  one  advantage  over  the 
trap  attached  to  a  plate,  in  that  it  may  be  removed  and  dropped 
into  water  while  eating,  avoiding  all  danger  of  disturbing  the 
form  of  a  deposit  in  chewing  food.  One  who  wears  a  plate  may 
have  one  plate  to  wear  at  meal-time  and  another  carrying  the 
trap  to  wear  at  other  times.  In  this  way  the  danger  of  dis- 
turbing the  deposit  in  chewing  food  will  be  obviated. 

On  these  cover-glasses  I  caught  the  fresh  deposits  in  the 
foiTQ  in  which  they  were  laid  down,  and  soon  learned  to  avoid 
those  which  were  too  thick  for  microscopic  study.  The  deposit 
would  invariably  begin  in  the  little  angle  formed  by  the  meeting 
of  the  gold  plate  and  the  cover-glass,  and  spread  from  that  out 
over  the  cover-glass.  It  was  desirable  to  remove  the  cover-glass 
before  it  was  completely  covered  with  deposit,  in  order  that  a 
thin  margin  would  be  presented  for  study.  Tlie  screws  were 
removed,  the  frame  lifted,  and  the  cover-glass  with  the  deposit 


82  SPECIAL    DENTAL    PATHOLOGY. 

transferred  to  the  fluids  for  washing,  staining  and  otherwise 
preparing  for  mounting.  When  the  material  was  mounted  in 
balsam,  without  other  preparation  than  the  removal  of  water 
with  alcohol,  it  became  so  transparent  that  nothing  could  be 
seen,  except  where  it  was  thickly  filled  with  calcium  salts,  and 
even  there  no  form  elements  could  be  discovered.  Therefore, 
some  kind  of  stain  became  necessary. 

Staining.  I  found  that  this  material  could  not  be  stained 
by  the  ordinary  processes  for  staining  tissues  or  micro-organ- 
isms, for  the  reason  that  all  of  the  stain  would  wash  out.  By 
using  stains  soluble  in  absolute  alcohol,  increasing  the  strength 
of  the  solutions,  and  leaving  the  specimens  in  them  from  twelve 
to  twenty-four  hours,  then  giving  an  hour  or  two  in  absolute 
alcohol  for  removal  of  excess  of  stain,  fairly  good  selective  and 
diffusive  stains  have  been  produced.  A  ten  per  cent  solution  of 
gentian  violet  in  absolute  alcohol,  and  a  saturated  solution  of 
eosin  in  absolute  alcohol,  gave  very  satisfactory  results.  Gen- 
tian violet  is  a  selective  stain.  Eosin  is  a  diffusive  stain.  Nigro- 
sin  answers  certain  purposes  very  well,  since  it  shows  selections 
which  other  stains  do  not.  Many  other  stains  have  been  tried 
but  have  not  given  better  results.  By  using  formalin,  four  per 
cent  solution  first,  as  a  mordant,  the  time  required  for  staining 
is  much  reduced.  Phenol,  twenty  per  cent,  produces  a  similar 
result. 

As  to  the  use  of  the  stains  mentioned,  eosin  is  good  for 
showing  the  general  forms  of  the  masses  composed  of  spherules. 
(See  Figures  124, 125  and  126.)  The  gentian  violet  is  a  selective 
stain  and  shows  the  structure  of  the  larger  masses  of  spherules. 
(See  Figures  131,  132  and  133.)  This  structure  is  made  up  of 
several  kinds  of  spherules,  i.  e.,  spherules  differing  chemically, 
and  because  of  these  individual  differences,  take  and  hold  the 
stain  differently  and  show  the  individuality  of  certain  similar 
spherules  by  similar  stains  or  differentiations  by  different 
degrees  of  color.  Some  of  these  stain  very  brightly,  some  assume 
a  dull  color,  and  others  only  enough  to  show  their  outline.  It  is, 
therefore,  a  very  valuable  agent.  Many  of  the  larger  masses 
are  shown  by  this  stain  to  be  built  up  of  minute  spherules  differ- 
ing from  each  other  in  some  chemical  character,  and  yet  acting 
together  in  building  these  compound  forms.  They  might  be  called 
mulberry  forms,  since  they  are  composed  of  various  little  round 
masses  which  we  may  call  the  primary  spherules.  These  are 
generally  no  larger  than  the  nucleus  of  an  ordinary  epithelial 
cell ;  so  small  indeed  that  they  may  circulate  in  the  blood  stream 


STUDIES    OF    SALIVARY    CALCULUS.  83 

without  interference,  or  probably  pass  through  the  glands  with 
the  usual  secretions,  when  there  is  an  overplus  of  the  material 
to  be  thrown  out,  or  in  any  other  condition  of  the  blood  in  which 
these  chemical  constituents  are  not  retained.  The  phenomena 
presented,  when  viewed  in  this  way,  are  of  wonderful  interest. 

Nigrosin  is  a  diffusive  stain  for  much  the  greater  part  of 
the  material,  but  it  has  one  point  of  differentiation  not  made  by 
any  other  stain  that  I  have  tried.  There  is  one  class  of  spherules 
in  many  of  the  specimens  —  not  in  all  —  that  nigrosin  leaves 
perfectly  transparent.  (See  Figures  129  and  130.)  This  spher- 
ule is  often  larger  than  others,  or  possibly  made  up  of  many 
smaller  spherules,  none  of  which  take  the  stain,  and  therefore 
are  invisible.  In  very  thin  deposits,  one  of  these  is  often  the 
center  of  a  cluster  of  other  small  spherules  which  take  the  stain. 
This  causes  them  to  appear  as  if  formed  around  an  opening.  In 
thicker  deposits  these  —  which  seem  to  have  been  the  first 
deposited  —  often  peep  through  among  the  darker  ones,  by 
which  they  are  nearly  covered,  as  tiny  stars  of  clear  light,  or 
as  larger  areas  of  light  where  they  have  less  covering.  This 
makes  nigrosin  a  very  interesting  stain.  It  is  curious  to  note 
the  greater  variations  in  markings  brought  out  by  these  differ- 
ent stains,  and  the  demonstrations  of  differences  in  chemical 
preferences  by  spherules  which  are  thrown  out  of  the  circulation 
together  and  so  intimately  associated.  Perhaps  some  other  per- 
sons more  familiar  with  the  modern  methods  of  handling  stains 
and  mordants,  and  also  with  more  time  at  command,  would  be 
able  to  produce  other  differentiations  which  I  have  not  found. 
The  differentiations  mentioned  are  represented  as  well  as  pos- 
sible in  plain  light  and  shade  in  the  series  of  photomicrographs 
presented.  They  are,  however,  a  very  poor  representation  of 
what  is  actually  seen  with  the  microscope. 

This  staining  of  these  different  globulins,  which  make  u]) 
the  agglutinin  of  salivary  calculus,  is  not  different  in  theory  or 
in  what  it  teaches,  from  the  staining  of  tissues  when  properly 
prepared,  cut  in  fine  sections  and  then  their  different  parts 
brought  into  bold  view  by  selective  stains.  The  epithelial  cells 
stain  differently  from  the  connective  tissue  cells.  In  each  of 
these  again,  the  nucleus  stains  differently  from  the  body  of  the 
cell.  In  each  case,  the  differential  stain  is  a  response  to  chem- 
ical preference  —  an  exhibit  of  chemotaxis  founded  upon  a  chem- 
ical difference  in  the  particular  portion  of  tissue. 

These  selective  stains  of  the  spherules  of  agglutinin  show 
conclusively  that  this  subst;inc(^  is  made  u])  of  <-i  iniinhei'  of  glob- 


84  SPECIAL,   DENTAL    PATHOLOGY. 

ulins  wliicli  differ  in  some  particular  features  of  their  cliemical 
structure.  We  can  not  from  these,  select  and  name  the  globulins 
represented.  It  seems  best,  then,  that  we  continue  to  call  this 
mass  derived  from  the  saliva  the  agglutinin  of  calculus. 

Deposits  classified. 

I  have  previously  spoken  of  three  classes  of  deposit.  (1) 
Agglutinin  of  salivary  calculus  loaded  with  calcium  salts,  and 
of  a  greyish-white  color;  the  central  zone.  (2)  A  considerable 
deposit  of  the  same  agglutinin,  so  far  as  I  am  able  to  determine 
by  physical,  microscopical  and  staining  tests,  which  carries  with 
it  very  little  of  calcium  salts.  When  very  fresh,  this  is  semi- 
transparent  or  slightly  greyish;  the  middle  zone.  (3)  A  still 
more  scant  deposit,  fully  transparent,  which  in  staining  tests 
seems  to  lack  certain  of  the  classes  of  spherules  of  the  agglu- 
tinin present  in  the  other  two  forms;  the  outer  zone.  Those 
spherules  which  stain  brightly  with  gentian  violet  are  missing 
in  the  outer  zone.  It  is  possible,  however,  that  the  presence  of 
the  calcium  salts  may  so  affect  the  staining  as  to  be  deceptive 
on  this  point.  These  zones  are  shown  best  in  Figures  126  and 
131. 

These  three  zones  are  usually  present  in  the  material  laid 
down  in  each  paroxysm;  the  greyish- white  deposit  occupying 
the  center  of  the  area,  surrounded  by  the  semitransparent  or 
middle  zone,  and  still  farther  out  by  the  transparent  or  outer 
zone.  These  differences  are  not  usually  very  sharply  defined, 
but  grade  imperceptibly  into  each  other.  The  central,  or  grey- 
ish-white, form  is  never  seen  alone,  but  is  surrounded  by  the 
other  two.  The  semitransparent  and  the  transparent  zones  are 
often  seen  without  the  greyish-wbite  zone.  Not  very  frequently 
the  transparent  zone  is  seen  without  either  of  the  others. 

Paroxysmal,  characters. 

While  I  was  studying  the  masses  of  calculus  by  aid  of 
staining  agents,  other  studies  were  also  being  carried  on.  One 
of  the  first  determinations  certainly  made  was  that  the  deposit 
of  salivary  calculus  is  paroxysmal.  AVith  myself,  and  others  in 
good  health,  whom  I  have  had  the  opportunity  to  examine  suffi- 
ciently for  a  determination,  there  has  been  no  exception  to  this 
rule.  Some  persons,  who  were  in  a  very  low  state  of  health, 
were  regularly  examined  by  others,  and  reported  as  having  a 
deposit  every  day  on  plates  worn.  Tbis  deposit  was  of  the  semi- 
transparent  and  transparent  agglutinin  of  calculus,  but  none 


STUDIES   OF    SALIVARY    CALCULUS.  85 

of  the  greyish-white  form,  containing  calcium  salts.  These  per- 
sons may  have  paroxysms  of  the  deposit  of  the  white  form. 
This  point  needs  further  investigation. 

For  a  considerable  time  the  cause  of  these  paroxysms  of 
deposit  eluded  me.  I  instituted  the  most  rigid  scrutiny  of  my 
own  actions  and  doings  —  how  I  was  employed,  how  I  slept  and 
what  I  ate.  For  some  time  I  weighed  the  food  eaten  at  break- 
fast and  dinner  and  took  notes  of  my  noon  lunches  at  the  res- 
taurant. 

The  plan  of  study  was  not  long  in  bringing  results.  It  was 
found  that  palatable  meals,  eaten  of  heartily,  and  apparently 
well  digested,  were  followed  by  paroxysms  of  deposit  of  salivary 
calculus.  (See  Figures  131,  132  and  133.)  These  meals  did  not 
produce  any  notable  discomfort,  but  after  studying  the  matter 
more  closely,  I  found  there  was  something  of  a  heaviness  and 
languor  following  such  meals,  but  nothing  more.  One  of  my 
students,  a  jolly  and  rather  fat  fellow,  expressed  the  matter  in 
this  way.  He  told  me  that  after  hearing  my  lecture  on  this 
point,  he  concluded  he  would  try  it  himself,  for  he  had  to  have 
calculus  removed  from  his  teeth  very  frequently.  He  said  he 
''cut  his  meals  in  two  in  the  middle."  He  didn't  get  hungry,  he 
didn't  lose  flesh,  he  didn't  have  any  more  calculus  on  his  teeth. 
*'But,"  said  he,  'Hhat  isn't  half  the  story.  Before  trying  this 
out  I  was  absolutely  unable  to  read  or  study  for  more  than  one 
hour  of  an  evening.  I  would  go  to  sleep  in  spite  of  everything 
I  could  do.  But  now  I  can  work  from  eight  to  eleven  every 
evening  and  feel  good  all  the  time.    No  more  big  meals  for  me." 

When  this  matter  was  determined,  I  stopped  the  paroxysms 
of  deposit  in  my  own  mouth  completely,  except  as  I  produced 
them  in  the  study  of  the  effect  of  d.ifferent  articles  of  food.  Or, 
if  I  wanted  a  fresh  deposit  of  calculus  for  study,  I  was  able 
to  get  it.  If  I  went  to  my  restaurant  and  ordered  boiled  pigs' 
feet  and  sauerkraut  and  ate  the  full  order  served,  I  was  sure 
of  a  flood  of  calculus  within  three  hours,  which  might  continue 
several  hours.  If  I  ordered  the  pigs'  feet  and  sauerkraut  and 
ate  but  half  the  order  served,  I  had  no  calculus.  Braised  meats 
of  any  kind,  with  rich  brown  gravy,  eaten  heartily,  usually  pro- 
duced a  paroxysm  of  deposit,  but  if  eaten  more  moderately 
produced  no  such  effect.  I  can  drink  one  glass  of  milk  before 
retiring  at  night  and  rise  in  the  morning  with  a  perfectly  clean 
plate.  If  I  drink  two  glasses  of  milk  before  retiring,  I  will  have 
a  good  specimen  of  calculus  next  morning.  The  kind  of  food 
seems  to  make  veiy  little  difference,  an  excessive  amount  of 


86  SPECIAL   DENTAL    PATHOLOGY. 

almost  any  food  produces  a  deposit.  I  found  that  I  could  induce 
a  paroxysm  of  dei^osit  with  almost  any  good  nutritious  food, 
even  simple  bread  and  butter. 

One  day  for  luncheon  I  ate  two-thirds  of  an  order  of  ' '  baked 
young  pig  and  sweet  potatoes."  When  I  returned  from  lunch 
I  was  more  careful  than  usual  in  cleansing  my  plate.  This  was 
at  two  o'clock.  During  the  afternoon  I  was  busy  with  other 
things  and  forgot  the  matter.  That  evening  a  few  minutes  after 
six  o'clock,  I  examined  the  plate  and  within  these  four  hours,  a 
flood  of  calculus  had  been  poured  out,  which  covered  up  and  hid 
my  trap  completely  and  filled  both  buccal  sides  of  my  plate 
nearly  to  the  cuspids.  All  of  the  central  zone  was  almost  snow 
white.  I  cleaned  the  plate  carefully  and  ate  my  dinner.  When 
I  stopped  writing  at  midnight  the  plate  was  found  to  be  clean. 
It  was  also  clean  next  morning.  This  paroxysm  with  its  extraor- 
dinary amount  of  material  had  come  and  gone  within  the  four 
hours  after  eating.  Curiously  enough,  the  more  I  study  this 
]ioint  regarding  the  duration  of  paroxysms  the  shorter  I  find 
them. 

Gathering  calculus  direct  from  the  parotid  gland. 

In  order  to  determine  definitely  that  calculus  comes  into  the 
mouth  as  calco-globulin,  I  instituted  another  series  of  experi- 
ments. Saliva  was  collected  before  it  reached  the  mouth  by  the 
intubation  of  Stenson's  duct.  Special  apparatus  was  designed 
for  the  purpose:  a  tube  was  passed  into  the  duct  and  the  saliva 
was  collected  in  a  test-tube,  without  ever  having  touched  the 
tissues  of  the  mouth.  (See  Figures  135  and  136.)  A  test  of  the 
saliva  so  collected,  by  placing  it  in  the  incubation  oven,  showed 
it  to  be  sterile. 

I  selected  two  young  men,  who  frequently  had  calculus  on 
their  teeth,  and  took  them  out  to  luncheon.  I  gave  each  of  them 
a  plate  with  two  whole  pigs'  feet  which  had  been  boiled  with 
cabbage,  and  they  were  invited  to  eat  anything  else  they  wished. 
The  pigs'  feet  had  been  boiled  until  they  were  soft  and  tender. 
Of  the  two  young  men  in  the  first  group  that  I  employed  for  this 
purpose,  one  of  them  ate  all  of  his  order,  g-nawing  the  bones 
clean.  The  other  picked  out  certain  bits,  and  did  not  eat  more 
than  one-fourth  of  the  order.  About  two  hours  afterward,  tubes 
were  put  into  the  ducts  and  the  saliva  was  found  to  run  fairly 
well.  AVe  will  call  these  two  men  A  and  B.  In  three-quarters  of 
an  hour  8  cc.  were  collected  from  A  and  6  cc.  from  B. 


STUDIES    OF    SALIVAEY    CALCULUS.  87 

Cover-glasses  for  catching  the  deposit  were  |)laced  to  the 
bottom  of  the  test-tubes  before  beginning  the  collection  of  the 
saliva,  and  remained  there.  As  the  running  of  the  saliva  con- 
tinued, it  was  noticed  that  in  the  case  of  A,  who  ate  the  full 
amount  of  the  order  of  pigs'  feet,  the  saliva  was  turbid  in  the 
tube;  in  that  of  B,  who  ate  only  a  part  of  the  order,  it  was  clear. 
A  little  later,  in  the  saliva  of  A,  a  deposit  of  snow-white  calco- 
globulin  could  be  seen  upon  the  cover-glass  in  the  bottom  of  the 
tube;  in  that  of  B,  toward  the  close  of  the  experiment,  there  was 
some  deposit  on  the  cover-glass,  but  it  was  vevj  slight.  The 
saliva  in  the  tube  remained  clear. 

At  the  end  of  three-quarters  of  an  hour  the  experiment  was 
discontinued,  believing  that  we  had  enough  to  make  a  good 
test.  The  tubes  were  then  set  away.  I  did  not  put  them  in  the 
incubation  oven,  as  the  weather  during  the  day  had  been  98°  in 
my  room,  making  the  room  itself  an  incubation  oven,  and  it 
remained  so  through  most  of  the  night.  The  next  morning  T 
found  the  saliva  clear  in  lioth  tubes.  In  that  of  A,  a  snow-white 
deposit  was  piled  up  on  the  cover-glass  —  all  that  would  lie  on 
it.  The  cover-glass  was  %  inch  in  diameter  and  was  piled  up 
fully  1/4  inch  high  from  the  8  cc.  of  saliva,  only  7  cc.  of  which 
were  above  the  cover-glass,  and  the  space  under  the  cover-glass 
was  well  packed  with  calco-globulin.  In  the  tube  from  B  there 
was  a  very  good  microscopic  specimen  of  calco-globulin  on  the 
cover-glass,  but  no  great  accmnulation. 

Any  one  may  make  the  tubes  and  conduct  a  similar  series 
of  experiments.  The  ducts  should  be  examined  in  each  case 
before  anything  else  has  been  done.  In  quite  a  number  of  per- 
sons, Stenson's  duct  was  found  to  be  so  small  that  a  tube,  the 
lumen  of  which  was  large  enough  to  serve  the  purpose  well  in 
collecting,  could  not  be  passed  into  it.  In  others,  the  duct  was 
so  tortuous  that  it  was  exceedingly  difficult  to  follow  it  with  a 
tube  to  sufficient  depth  for  the  tube  to  hold  well.  Many  diffi- 
culties arise  which  must  be  overcome.  Persons  must  be  selected 
who  are  known  to  have  considerable  deposits  of  calculus,  and  it 
should  be  determined  that  the  tubes  may  be  passed  into  the 
ducts.  Then  they  should  cat  a  heavy  meal  of  food  that  is  highly 
nutritious  and  easily  digested,  for  the  purpose  of  arousing  a 
paroxysm.  The  tube  should  be  inserted  about  one  and  a  half 
hours  after  the  meal  and  observed  carefully  in  order  to  catch 
the  paroxysm  at  its  height,  for  it  is  not  uncommon  for  these 
paroxysms,  with  a  great  flow  of  calculus,  to  be  over  in  half  an 
hour  after  they  begin. 


88  SPECIAL    DENTAL    PATHOLOGY. 

The  gathering  of  calculus  in  this  way  marks  a  step  in 
advance  in  our  study  of  tliis  deposit,  one  that  will  stand  for  all 
time,  showing  whence  comes  the  calculus  that  we  find  upon  the 
teeth.  In  the  endeavor  to  collect  calculus  in  this  way,  a  great 
many  failures  will  occur.  We  must  not  take  persons  who  have 
never  been  loiown  to  have  calculus  on  their  teeth,  and  expect 
to  find  accumulations  in  the  saliva  drawn.  We  must  not  expect 
to  succeed  in  every  case,  even  though  we  have  made  the  very 
best  possi1)le  selection  of  a  subject.  If  a  person's  digestion  hap- 
pens not  to  be  good  at  the  time,  the  food  may  arouse  no  flow  of 
calculus,  because  if  the  food  is  not  well  digested,  there  will  be 
no  excess  of  calco-globulin. 

Deposits  of  hard  salivary  calculus  are  occasionally  found 
in  the  ducts  of  the  salivary  glands,  the  nidus  for  such  deposits 
usually  being  some  foreign  substance,  such  as  a  splinter  of  a 
wooden  toothpick,  which  has  been  accidentally  passed  into  the 
duct.  I  have  seen  several  such  calculi  of  considerable  size. 
Figures  140,  141  and  142  are  actual  size  reproductions  of  photo- 
graphs of  calculi  removed  from  the  ducts  of  the  salivary  glands. 
There  is  also  shown  in  Figure  143  a  tremendous  deposit  which 
was  found  in  a  kidney  of  a  cadaver  in  the  anatomical  laboratory. 

Globulin. 

A  globulin  is  any  one  of  a  class  of  albuminous  proteid  com- 
pounds insoluble  in  water  or  alcohol,  but  soluble  in  weak 
solutions  of  the  neutral  salts.  The  animal  globulins  include 
fibrinogen,  serum  globulin  or  paraglobulin,  globin,  myosinogen, 
ciystallin,  and  vitellin.  This  definition  was  written  after  con- 
sulting a  number  of  medical  and  general  dictionaries,  but  is  not 
quite  like  any  one  of  them.  I  have  been  unable  to  determine 
definitely  why  this  term  glo1)ulin  has  been  applied  to  these 
products,  but  must  suppose  that  some  one  has  seen  the  spherical 
forms,  and  consequently  applied  the  term  globulin. 

Globulin  is  recognized  by  physiological  chemists  as  a  highly 
nutrient  material  held  in  the  blood,  body  juices  and  flesh,  in 
readiness  for  use  in  tissue  metabolism  of  the  constructive  type; 
a  nutrient  material  in  excess  of  immediate  needs,  but  ready  for 
immediate  use.  In  this  respect  the  globulins  are  very  important 
in  the  nutritional  processes.  As  previously  stated,  in  this  method 
of  procedure  the  agglutinin  of  calculus  is  found  to  respond  to 
the  usual  tests  for  glol)ulin. 


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Fig.  131.  The  appoaranco  given  by  an  accnnuilation  rai)i(ll.v  i"ornic«l  (witliin  four 
hours),  stained  with  gentian  violet,  after  having  been  coagulated  by  i)hen()l.  '^  \)or 
cent,  solution  in  water,  and  the  uncombined  phenol  carefully  disstdved  out  by 
repeat«d  washing.  The  lower  right-hand  corner  uf  the  picture  was  in  a  conii-r  of  the 
frame. 

It  will  be  n  )ticed  in  this  that  certain  of  tlie  snialier  splieruics  stain  uuuc  promi- 
nently than  others,  and  that  the  larger  spherules  are  agglomerations  of  the  smaller 
spherules.  This  sj)ecinu'n  was  jicrfectly  transjiarent  before  coagid.-ition  with  phenol. 
At  certain  points  the  accuuudation  was  too  thick  for  photography. 

10 


Fig.  133. 


Fig.  132.  Appearance  given  by  an  accumulation  forming  in  about  ten  hours, 
stained  by  gentian  violet  after  it  had  been  exposed  to  4  per  cent  formalin  for  one 
hour,  and  repeatedly  washed  to  remove  nneombined  formalin.  It  remained  in  tlie 
staining  solution  twenty-four  hours,  and  was  washed  in  absolute  alcohol,  which  was 
repeatedly  changed,  and  much  of  the  time  kept  in  motion  for  about  two  hours. 

This  specimen  gives  a  beautiful  appearance  when  seen  in  the  microscope, 
but  as  the  stain  is  a  bright  blue  with  gradations  of  the  intensity  of  color  in  the 
different  primary  spherules,  it  is  only  imperfectly  represented  by  photography.  The 
conglomerate  structure  can,  however,  be  made  out  fairly  well. 

Fig.  133.  From  the  same  specimen  shown  in  Figure  132,  showing  only  the  central 
portion  of  the  field.  In  this  a  multitude  of  fine  spherules  that  take  the  stain  sharply 
appear  in  the  make-up  of  the  large  spherules.  In  some  specimens  the  masses  are  made 
up  of  primary  spherules  that  take  the  stain  differently,  showing  distinct  chemical 
differences  in  these  primary  spherules  that  join  in  making  up  the  larger  compound 
forms.  Thus  far  this  is  well  shown  only  by  the  gentian  violet  stain,  following 
formalin  as  a  mordant.  Other  stains  may  yet  be  found  that  will  make  these  selec- 
tions and  be  better  for  photographing. 


studies  of  saltvaby  calculus.  89 

Agglutinin  of  salivary  calculus. 

As  yet  the  agglutinin  of  salivary  calculus  has  been  but 
partially  studied.  I  have  given  attention  for  the  most  part  to 
the  physical  phenomena  rather  than  the  chemical  qualities.  At 
present  the  former  are  much  the  more  important  qualities  to  be 
made  out.  When  a  substance  which  is  well  known  is  identified, 
that  is  sufficient.  What  it  does  in  the  new  position  in  which  it 
is  discovered  becomes  the  important  question.  I  have  adopted 
the  term  agglutinin  or  agglutinin  of  calculus  because  we  should 
have  a  distinctive  name  for  the  substance  as  it  appears  in  con- 
nection with  deposits  of  calculus,  to  distinguish  that  form  from 
every  other,  no  matter  what  it  may  be  chemically.  That  it 
comes  into  the  mouth  with  the  saliva  there  is  no  question. 

Agglutinin,  as  we  find  it  deposited  in  the  mouth,  when  taken 
up  in  the  fresh  state  —  as  a  deposit  discovered  while  being  laid 
down  during  the  day,  or  one  discovered  in  the  morning,  having 
been  laid  down  during  the  night  —  is  so  much  heavier  than  water 
that  it  will  sink  at  once.  It  will  do  the  same  in  fresh  saliva.  It 
is  probably  not  in  actual  solution  in  the  saliva  at  all,  but  is  dis- 
tributed in  the  form  of  very  small  primary  spherules.  From 
these  the  larger  masses  seen  in  deposits  are  built  up.  (See  Fig- 
ures 123  to  128.)  It  now  seems  that  there  can  be  no  question 
that  it  is  deposited  directly  from  the  saliva  almost  immediately 
upon  entering  the  mouth.  The  bulk  of  the  material  thrown  out 
is  carried  away  with  the  saliva  and  is  never  seen. 

It  requires  especially  favorable  conditions  for  it  to  become 
deposited  in  the  mouth,  upon  the  teeth,  or  even  upon  hard  sub- 
stances, as  plates,  worn  in  the  mouth.  As  will  be  mentioned 
later,  it  was  found  that  deposits  did  not  occur  on  a  cover-glass 
held  in  place  with  a  gold  frame,  unless  the  frame  was  made  with 
an  angle  or  rough  edge  which  would  give  opportunity  for  the 
first  deposit  to  occur.  A  study  of  the  deposits  occurring  on 
artificial  dentures  shows  that  the  beginnings  are  also  in  sheltered 
places.  This  should  lead  to  the  making  of  more  perfect  denture 
forms  so  that  deposits  will  not  occur. 

Consistency  of  the  spherules.  These  spherules  are  very 
soft  when  gathered  with  the  saliva  and  allowed  to  fall  upon  a 
cover-glass  fixed  in  the  bottom  of  a  test-tube  to  catch  them. 
They  will  accumulate  and  pile  up  on  the  cover-glass  until  after 
a  time  they  will  roll  down  the  sides  of  the  pile  and  over  the  edge 
of  the  glass.  A  little  disturbance  will  cause  them  to  roll  off  as 
they  accumulate  upon  the  glass.    If  the  tu])e  is  ko])t  still,  how- 

*io 


90  SPECIAL    DENTAL   PATHOLOGY. 

ever,  they  will,  in  the  course  of  a  few  hours,  become  attached 
to  the  glass  as  Avith  a  very  soft,  sticky  wax.  (See  Figure  137.) 
This  waxy  consistency  in  the  spherules  is  very  characteristic, 
for  it  is  by  this  that  they  take  hold  and  adhere  to  hard  sub- 
stances, which  form  nidi  for  the  gathering  of  calculus,  as  the 
teeth,  plates  and  various  hard  substances  placed  in  the  mouth, 
or  any  object  that  is  put  in  the  urinary  bladder  and  serves  as  a 
nidus.  Once  I  found  a  small  pen-knife  in  the  urinary  bladder 
of  a  girl,  which  had  acted  as  a  nidus  and  was  encrusted  with 
calculus.  Anything  of  this  kind,  or  sometimes  a  group  of  dead 
cells,  seems  to  act  as  a  nidus.  The  peculiar  characteristics  of 
the  globulin  spherule  are  such  as  to  cause  it  to  cohere  in  this 
way,  one  of  its  sides  flattening  down  upon  hard  substances; 
hence  it  gathers  on  teeth,  plates,  etc. 

From  this  description  it  will  be  noted  that  the  original 
spherule,  as  eliminated  from  the  salivary  glands,  or  other 
sources,  is  a  very  soft  mass  that  will  not  stand  alone  and  pre- 
serve its  rotundity,  if  laid  upon  a  flat  surface,  but  will  slowly 
come  to  stick  fast,  and  change  its  form,  presenting  a  flat  side 
upon  the  substance  to  which  it  sticks.  Others,  each  falling  upon 
a  layer  of  these,  will  stick  to  them,  and  so  on  until  a  very  con- 
siderable accumulation  may  be  built  up.  The  building  of  these 
depends  very  largely  upon  the  sticky  character  of  the  spherules. 

We  may  get  special  preparations  in  the  following  way: 
While  the  saliva  is  still  running,  place  the  point  of  a  small  glass 
pipette  into  the  liquid  which  has  accumulated  in  the  test-tube, 
and  draw  some  of  it  into  the  tube  of  the  pipette.  Place  the 
pipette  so  that  it  will  be  perpendicular  with  the  point  on  a  cover- 
glass,  and  let  it  stand  for  some  little  time  to  permit  the  spherules 
to  sink  to  the  point.  Then  slight  pressure  upon  the  rubber  bull) 
will  cause  a  little  of  the  liquid  to  issue,  in  the  form  of  a  drop,  on 
the  cover-glass.  Preparation  should  have  been  made  before- 
hand, and  this  should  now  be  placed  in  a  moist  chamber,  to 
prevent  drying,  and  should  remain  there  several  hours,  in  order 
that  the  globulin  may  become  stuck  fast  to  the  cover-glass.  Then 
it  can  be  passed  into  alcohol,  or  into  staining  fluids,  and  handled 
so  as  to  make  the  preparation  such  as  is  desired  for  mounting. 

To  gain  some  idea  of  the  consistency  of  these  spherules,  one 
may  imagine  spherules  made  of  a  soft  wax,  warmed  until  it 
becomes  so  sticky  that  the  spherules  will  first  cohere  and  then 
gradually  coalesce.  Each  will  sink  in  among  the  rest  and  gradu- 
ally lose  its  identity.  In  settling  down,  there  is  the  tendency  to 
form  larger  rounded  masses.     This  is  apparent  on  examining 


STUDIES   OF    SALIVARY   CALCULUS.  91 

the  material  stained  on  cover-glasses.  Some  of  these  are  in  the 
form  of  more  or  less  flattened  spheres. 

As  to  softness,  the  spherules  which  contain  a  large  amount 
of  calcium  salts  seem  to  be  just  as  soft,  or  if  anything  a  little 
softer,  than  those  spherules  which  contain  no  calcium  salts,  so 
far  as  the  eye  can  detect. 

Globulin  and  salts  inseparable.  The  spherules  containing 
calcium  salts  are  in  no  sense  hard  calco-globulin,  but  they  seem 
to  be  chemically  combined  nevertheless.  The  one  can  not  be 
dissolved  without  dissolving  the  other.  It  may  be  possible  to 
dissolve  the  globulin  and  precipitate  the  salts  by  the  addition  of 
chemicals,  but  in  everj^  attempt  which  I  have  made  to  isolate  the 
salts  from  the  globulin  without  adding  chemicals,  the  whole 
body  has  been  dissolved,  salts  and  globulin.  I  tried  hot  water, 
and  after  five  days,  six  hours  per  day,  at  a  temperature  of 
206°  F.  —  209  is  the  boiling  point  at  our  altitude,  barometer  30 
(sea  level)  — a  solution  was  practically  complete,  only  a  very 
scant  waxy  deposit  remained.  Practically  the  whole  material 
became  hydrolized  and  on  evaporation  formed  ciystals  not 
resembling  the  crystals  of  calcium  phosphate.  No  precipitate 
of  calcium  salts  was  discovered ;  no  amount  of  mechanical  agita- 
tion seems  to  succeed  in  shaking  out  a  precipitate  of  calcium 
salts  from  the  soft  deposits  of  calculus. 

Deposits  during  illness. 

I  have  also  discovered  another  feature  of  this  deposit  which 
is  very  interesting,  though  not  well  worked  out.  A  dentist,  who 
was  interested  with  me  in  the  study  of  this  subject,  reported 
that  the  full  artificial  dentures  worn  Iw  his  wife,  who  was  a 
paralytic,  were  covered  with  a  thin  veil  of  the  transparent  zone 
of  salivary  calculus  every  day.  It  was  necessaiy  for  liim  to 
clean  these  dentures,  as  she  could  not  do  so,  and  he  examined 
them  carefully  each  day  for  a  considerable  time.  If  the  cleaning 
was  neglected  for  a  few  days,  the  deposit  was  considerably 
thickened  and  became  of  a  brownish  color  and  the  cheese-like 
consistence.  In  this  way  she  seemed  to  be  losing  by  leakage 
through  the  secretion,  so  to  speak,  the  scant  supply  of  globulin 
which  was  formed  by  her  very  imperfect  digestion  of  food. 

In  1912  I  spent  three  summer  months  on  my  farm  under 
what  seemed  to  be  ideal  conditions  for  recovery  from  a  neuritis. 
I  slept  in  a  bungalow,  the  walls  of  which  were  made  of  screens, 
except  a  dressing-room  and  a  bathroom.  Practically,  we  had 
our  meals,  lived  and  slept  in  the  open  air.    I  also  spent  most  of 


92  SPECIAL   DENTAL,   PATHOLOGY. 

the  time  of  daylight  in  the  woods  directing  some  lahorers.  T 
was  taldng  about  as  much  out-door  exercise  as  my  condition 
would  allow. 

During  this  time  I  had  much  more  deposit  of  calculus  than 
when  at  home  pursuing  my  usual  work.  That  is,  a  deposit 
seemed  more  easily  aroused.  This  was  a  surprise,  and  I 
watched  it  very  carefully  and  made  the  best  comparison  I  could 
with  my  consumption  of  food.  While  this  influenced  it  sharply, 
a  deposit  was  much  more  easily  aroused  than  formerly.  After 
my  return  to  my  usual  employments,  this  condition  ceased.  I  do 
not  know  why. 

This  circumstance,  taken  with  what  we  see  among  our 
patients,  seems  to  confirm  the  supposition  that  there  are  some 
systemic  conditions  which  favor  the  deposit  of  calculus,  besides 
the  quantity  of  food  taken. 

In  this  we  must  remember  also,  that  there  are  many  people 
who  never  have  a  deposit  of  calculus  upon  their  teeth.  Yet,  so 
far  as  we  can  see,  their  habits  of  living  are  the  same  as  those 
of  other  people.  They  are  not  ditferent  in  physical  qualities 
nor  in  degree  of  general  health.  In  the  consideration  of  the 
deposit  of  calculus  this  must  not  be  overlooked.  It  speaks  very 
emphatically  of  a  calculus  dyscrasia  of  which  we  have  as  yet  no 
tangible  idea. 

A  few  times  I  have  seen  the  deposit  of  agglutinin  in  the 
clear  form  so  abundant  that  while  it  did  not  appear  to  the  eye 
in  its  clear,  transparent  freshness,  it  would  hide  the  plate  com- 
pletely when  coagulated  by  boiling  water,  in  which  it  would  be 
whitened  and  become  opaque.  A  deposit  of  this  extent  is  evi- 
dently quite  rare,  but  I  have  seen  it  several  times.  It  has 
occurred  a  few  times  on  my  own  plate,  in  conjunction,  however, 
with  a  whiter  deposit  about  the  openings  of  the  ducts  of  the 
glands.  This,  with  myself,  has  always  occurred  during  some 
illness.     (See  Figures  138  and  139.) 

In  passing,  I  may  mention  the  fact  that  not  infrequently 
calculus  is  found  on  bullets  and  other  metallic  substances  lodged 
in  the  flesh,  which  have  remained  for  some  time.  This  calculus 
as  I  have  examined  it,  particularly  on  lead,  has  been  softer  than 
the  calculus  formed  in  the  saliva  or  in  the  urinary  bladder. 
In  some  specimens  it  has  been  so  soft  that  I  could  crumble  it 
with  my  fingers,  and  yet  there  was  no  doubt  whatever  of  its 
character.  This  shows  plainly  that  calculus  may  also  be 
deposited  from  serum  exuding  from  the  tissues,  and  is  therefore 
carried  by  the  blood  stream. 


Tig.  134. 


Fig.  134.  A  slight  but  vory  diffuso  deposit  oeeiirring  slowly  at  tlio  ending  of  a 
paroxysm.  There  is  a  sprinkling  of  sphernles  thid  take  the  stain  sharply,  among 
many  fine  sphendes  that  do  not,  and  a  considerable  ninnl)er  of  small  eircles  scattered 
over  the  field  formed  by  accumulations  around  spherules  which  do  not  take  the  stain. 


10b 


Fig.  135. 


Fig.  135.  Intultulinii  of  Stfiisoii's  duct  for  tho  purpose  of  eollcctiug  the  saliva 
as  it  comes  from  tiie  parotid  gland.  A  silk  ligature,  previously  tied  around  the  brass 
tube,  is  tied  to  a  bicuspid  tooth  to  hold  the  tube  in  the  duct.  A  brass  wire  is  so 
bent  as  to  hold  a  disk  crosswise  of  the  test-tube.  This  disk  supports  a  cover-glass. 
(See  Figure  136.)  As  the  saliva,  which  drops  from  the  brass  tube,  accumulates  in 
the  test  tube,  it  will  be  cloudy  if  it  contains  much  caleo-globulin,  and  the  spherules 
will  gradually  settle  and  collect  upon  the  cover-glass.   (See  Figure   137.) 


Fig.  136. 


Fig.  137. 


Stciisnn's    (liii't. 

This  liy;atiire  is 
t  from  slii)ping 
IKisition  ill  tost- 


FlG.  136.  liituhiifioii  set  for  confctiiijj  s;ili\:i  direct  froii 
A,  C'amila  for  iiitubatioii  tul)o.  b,  Tube  witli  siliv  lifjatiirc  attaclu-d. 
tied  to  a  l)ieusj)id  toolli  after  the  tube  is  in  the  duct,  preveutinjr 
out.  c,  Wire  witli  disk  attaciied,  to  hold  cover-gia.ss,  d.  in  li(.ri/.oiit;i 
tube.     E,  Test-tube   for  collecting  saliva. 

Fig.  137.  Eepresentatiou  of  the  test-tube  with  saliva  containing  calco-globulin. 
The  saliva  is  at  first  cloudy  and  gradually  clears  as  (he  sphendes  settle  upon  th.> 
cover-glass.  In  exc(>ssivc  pjiroxysuis  the  spliciulcs  will  jdle  uji  on  the  cover-glass 
until  it  will  hold  no  niorc  and  then  roll  olV  :ind  accumulate  iti  tlic  bottom  of  the 
test-tube. 


'7  »     V'    ' 


Fig.  138. 


Fig.  138.  This  is  a  deposit  of  a  peculiar  tyiK-  that  seems  not  to  contain  calcium 
salts,  but  will  form  a  cheese-like  accumulation  on  the  teeth  or  on  dentures.  When 
cleaning  is  neglected  for  a  few  days,  this  becomes  too  stiff  to  be  removed  with  a 
brush,  but  may  be  scraped  off  with  the  finger  nail.  This  form  has  been  observed 
oftenest  on  dentures  of  persons  whose  nutritive  powers  are  very  low.  It  is  very 
persistent  in  some  confirmed  paralytics.  It  has  not,  however,  been  sufficiently 
studied.     Nigrosin  stain. 

Fig.  139.  This  shows  a  deposit  of  finer  spherules  of  a  type  of  material  similar 
to  that  shown  in  Figure  138.     Nigrosin  stain. 


STUDIES   OF    SALIVARY    CALCULUS.  93 

It  has  been  with  some  difficulty  that  I  have  arrived  at  the 
conclusion  that  so  important  a  nutritional  substance  as  the 
globulins  are  shed  out  with  the  secretions  and  become  a  prin- 
cipal factor  in  the  production  of  such  a  substance  as  salivarj- 
calculus,  but  the  facts  recited  force  this  conclusion. 

I  do  not  know  how  many  persons  in  very  poor  physical  con- 
dition are  having  such  deposits  as  have  been  mentioned,  or  are 
losing  the  globulin  from  their  blood  in  this  way.  My  finding, 
however,  is  a  strong  suggestion  that  this  may  be  a  mode  of 
draining  away  the  nutritive  power  of  the  blood  in  such  con- 
ditions. 

Chemistry  of  the  deposits. 

The  chemistry  of  these  deposits  needs  closer  investigation. 
It  seems  now  that  the  following  supposition  may  be  foimd  cor- 
rect :  The  greyish-white,  or  central  zone,  of  the  deposit  is  com- 
posed, in  the  main,  of  a  semifluid  calco-globulin,  but  has  mixed 
with  it  more  or  less  primary  globules  not  containing  calcium 
salts.  The  mixture  of  calco-globulin  within  the  mass  becomes 
thinner  as  we  proceed  from  the  center  outward,  until  at  some 
certain  point  we  have  globulin  only,  as  found  in  the  outer  or 
transparent  zone.  Physical  examination  of  the  mass  denotes 
this  change  and  also  the  observation  of  the  hardening  process 
shows  the  two  parts  to  act  differently.  The  white  portion  will 
partly  decompose,  leaving  a  stony,  hard  calculus,  while  the  clear 
portions  will  harden  first  to  the  consistence,  but  not  the  color, 
of  cheese,  and  finally  break  up  and  disappear.  It  is  at  first 
slightly  yellow,  almost  transparent,  and  becomes  opaque  and  of 
a  darker  color  as  it  grows  older.  Whether  or  not  the  lactic  acid 
formed  in  the  mouth  has  any  important  action  in  the  removing 
of  calcium  salts  from  the  more  thinly  scattered  deposits,  and, 
in  this  way  preventing  the  hardening,  may  be  mentioned  as  one 
of  the  undefined  chemical  problems  of  minor  importance. 

Whatever  the  full  truth  may  be  as  revealed  by  future  dis- 
covery, the  fact  will  remain  that  in  the  ordinary  paroxysmal 
deposit  of  persons  in  good,  or  fair  health,  the  three  zones  of 
deposit  will  appear,  varying  widely  in  the  proportions  of  each. 
The  deposit  close  about  the  opening  of  the  ducts,  the  central 
zone,  carries  the  bulk  of  the  calcium  salts. 

A  condition  of  general  deposit  of  calculus,  about  practically 
all  of  the  natural  teeth,  is,  however,  occasionally  seen.  These 
are  generally  neglected  cases  in  which  no  effort  has  been  made 
to  keep  the  mouth  clean.    In  such  cases,  it  luis  seemed  to  me 


94  SPECIAL    DENTAL    PATHOLOGY. 

that  there  is  established  a  condition  of  putrefactive  decomposi- 
tion which  acts  as  a  preventive  of  the  formation  of  lactic  acid, 
or  neutralizes  the  lactic  acid  formed.  The  study  of  these  changes 
presents  the  opportunity  for  some  chemist  to  do  an  important 
work. 

Hardening  of  salivary  calculus.  The  chemistry  of  the 
hardening  of  salivary  calculus  seems  to  have  no  literature. 
That  it  is  deposited  in  a  soft  condition  and  slowly  becomes  hard, 
is  stated  by  many  writers.  With  that  statement  the  subject  is 
dropped.     ^ 

I  have  only  begun  some  investigation  of  this  process  from 
the  physical  side.  The  hardening  is  found  to  be  accompanied 
by  putrefactive  decomposition  of  the  agglutinin  during  which 
the  transparent  portions,  as  well  as  the  white  zone,  first  become 
opaque  and  yellow,  diminishing  very  much  in  bulk.  If  the  speci- 
men is  placed  in  clear  water,  this  soon  becomes  clouded  with  a 
growth  of  micro-organisms.  Then  the  changes  seem  to  go  on 
much  slower,  although  apparently  of  the  same  character,  but  the 
change  to  the  hard,  stone-like  form,  such  as  is  found  upon  the 
teeth,  does  not  occur.  Ordinarily  it  is  very  difficult  to  follow 
this  process  with  any  degree  of  accuracy  in  the  mouths  of 
patients.  It  is  also  proving  to  be  a  difficult  matter  to  contrive 
artificial  conditions  which  will  serve  much  better.  It  seems 
probable  now  that  the  hardening  can  not  be  studied  by  any  arti- 
ficial method  out  of  the  natural  position  in  the  mouth. 

I  have  placed  a  number  of  specimens  in  water  at  room  tem- 
perature and  some  at  body  temperature.  The  results  were 
similar  in  both.  Within  a  short  time  the  water  became  white 
from  the  growth  of  micro-organisms,  which  continued  for  a 
week  or  two.  Then  the  fluid  became  clear.  During  this  time 
the  deposit  lost  perhaps  three-fourths  of  its  bulk.  What 
remained  had  not  become  hard.  One  very  heavy  white  deposit 
was  placed,  plate  and  all,  in  clean  water  and  closed  with  a  close- 
fitting  lid,  but  not  sealed.  At  the  end  of  four  months  what 
remained  of  tlie  mass  was  of  a  yellow  color  and  so  soft  that  I 
could  pick  it  to  pieces  with  the  small  end  of  an  ordinary  wood 
toothpick,  finding  only  an  almost  imperceptible  resistance. 
Still  more  recently,  I  have  packed  masses  of  the  fresh  soft 
deposit  on  a  cover-glass  and  suspended  it  by  a  clutch  fastened 
in  the  cork,  and  corked  it  tightly  in  a  short  glass  tube  one  inch 
in  diameter.  In  the  bottom  of  this  tube  was  placed  a  piece  of 
cotton  with  as  much  water  as  it  would  hold  without  being  liable 
to  run.    This  specimen  was  taken  from  a  very  thick  paper-white 


STUDIES    OF    SALIVAKY    CALCULI'S.  95 

deposit.  At  the  end  of  the  second  day  it  was  much  too  hard  to 
brush  away;  in  five  days,  yellow  and  softer.  It  did  not  harden 
as  is  the  mouth. 

Knowledge  of  hardening  basis  for  prophylactic  teaching. 
The  meaning  of  a  wider  knowledge  of  the  deposit  of  salivary 
calculus  in  its  relation  to  prophylactic  work  can  hardly  be 
reckoned.  This  should  stand  as  the  basis  of  much  of  the  popular 
teaching  of  prophylaxis.  Our  people  should  learn  the  facts  in 
brief,  substantial  statements,  accompanied  with  equally  definite 
statements  as  to  how  to  deal  with  them.  Deposits  of  calculus 
of  any  degree  removed  twice  per  day  —  morning  and  evening  — 
will  do  no  harm  whatever  to  the  gingivae  or  to  the  teeth.  All 
people,  with  but  a  few  exceptions,  should  be  able  to  so  conduct 
their  food  habits  that  no  deposits  of  calculus  would  occur;  or, 
l^y  cleaning  after  each  meal,  calculus  may  be  prevented  from 
doing  harm  to  the  tissues. 

Explanatory  supposition. 

The  facts  here  stated  give  origin  to  some  suppositions  that 
seem  necessary  to  a  fuller  explanation  of  the  method  of  the 
instigation  of  the  paroxysms  of  deposit  of  this  material. 

The  most  rational  supi^osition  which  has  come  to  my  mind 
is  this :  With  a  very  full  meal  of  highly  nutritious  food,  with 
the  alimentary  apparatus  in  good  condition,  much  more  nutrient 
material  is  thrown  into  the  blood,  and  more  of  the  globulins  are 
formed  than  are  necessary  or  can  be  used.  At  a  certain,  or, 
perhaps,  variable  overaccumulation  of  these,  the  excess  is  shed 
out  with  the  secretions  and  excretions,  and  then  a  proper  equi- 
librium is  again  established.  This  marks  the  rise  and  decline  of 
the  paroxysm.  This  is  at  least  a  thinkable  explanation  of  a 
process,  as  yet  hidden,  which  seems  to  meet  the  now  known  facts 
and  affords  a  resting-place  for  thought  regarding  the  most 
common  form  of  paroxysm  which  l)egins,  rises  to  its  flood, 
abates  and  ceases  within  from  one  to  three  or  four  hours.  It  is 
rather  rare  that  I  have  seen  closely  watched  paroxysms  of  much 
longer  duration.  I  have  seen  a  number  which  did  not  continue 
for  more  than  half  an  hour.  A  much  closer  watch  than  had  at 
first  been  made,  has  convinced  me  that  paroxysms  lasting  two 
or  three  days,  as  I  have  heretofore  stated,  have  been  two  or 
more  paroxysms  in  close  succession  instead  of  a  single  parox- 
ysm, as  I  had  supposed.  This  statement  has  in  view  persons  in 
fairly  robust  health. 


96  SPECIAL    DENTAL   PATHOLOGY. 

In  order  to  keep  this  closer  watch,  it  has  become  necessary 
to  clean  off  some  portion  of  surface  receiving  deposit,  or  a  cer- 
tain part  of  the  trap  itself,  every  hour,  or  even  every  half  hour, 
until  no  more  deposit  is  discoverable. 

In  persons  in  chronic  ill  health,  and  especially  those  whose 
condition  is  that  of  marked  malnutrition,  an  almost  constant 
slow  deposit  of  agglutinin  seems  to  occur.  This  may  not  carry 
with  it  any  deposit  of  calcium  salts.  In  that  case  it  does  not 
harden  as  do  other  deposits,  but  settles  into  a  curd-like  mass 
which  strongly  resists  removal  with  the  brush,  but  may  readily 
be  scraped  away.  This  form  of  deposit  never  becomes  very 
hard.  The  material,  however,  gives  the  same  appearance  in 
stained  specimens  as  that  containing  calcium  salts.  This  form 
of  deposit  of  agglutinin  sometimes  creates  a  very  foul  condition 
of  the  plate  and  mouth  through  the  putrefactive  decomposition 
which  occurs  in  the  mass.  A  low  form  of  inflammation  of  the 
soft  tissues  occurs  wherever  this  decomposing  material  is  in 
contact  with  them. 

In  the  class  of  cases  just  mentioned,  the  opportunity  for 
the  careful  daily  observation  of  many  persons  has  not  occurred 
to  me,  but  daily  examinations  have  been  made  by  others  and 
reported  to  me.  From  what  I  have  learned,  it  would  seem  that 
the  nutritional  process  is  so  low  that  much  of  the  small  amount 
of  the  globulins  formed  are  leaking  away  with  the  secretions 
and  excretions,  and  these  are  being  lost.  This  condition  acts  to 
intensify  other  diseased  conditions,  or  may  occasionally  form 
the  basis  of  a  type  of  wasting  disease. 

Calco-globulin  in  other  secretions. 

I  have  not  yet  examined  other  secretions  than  the  saliva 
for  globulin.  The  literature  gives  but  little  information  on  the 
subject.  It  seems  to  me  probable  that  during  certain  hours 
after  heavy  meals  other  secretions  will  be  loaded  with  globulin 
the  same  as  the  saliva.  These  would  give  a  deposit  of  calculus 
if  a  nidus  happened  to  be  present,  as  occurs  in  the  urinary  and 
gall  bladders  and  at  some  other  points. 

Calculus  in  the  urinary  bladder  has  a  wide  literature,  but 
at  present  this  does  not  help  us.  While  we  find  many  matters 
dependent  upon  these  deposits  very  ably  and  fully  discussed, 
the  intrinsic  part  of  the  sul)ject  seems  to  have  had  no  very  care'- 
ful  examination. 


Fig.  140. 


Fig.  14]. 


Fig.  142. 


Figs.  140,  141,  142.  Reproductions  of  salivary  calculi  removed  Iroin  ducts  of 
salivary  glands.  Actual  sizes.  Specimens  from  JMorthwcstern  University  Dental 
Museum.  Figure  140  presented  by  Dr.  Edward  C.  Tyler,  Traverse  City,  Mich.  Fig- 
ure 141  by  Dr.  W.  R.  "Wolf,  Parsons,  Kan.  Figure  142  by  Dr.  P.  A.  Pyper,  Pontiac, 
111.  It  should  be  particularly  noted  that  these  deposits  occurred  from  the  saliva 
before  it  reached  the  mouth. 


1 1:'.. 


Fig.  143.  An  enormous  deposit  of  calculus  in  a  human  kidney.  Actual  size. 
This  specimen  was  found  iu  a  cadaver  in  the  anatomical  laboratory  of  Northwestern 
University  Dental  School,  by  Dr.  William  Bebb,  curator  of  the  Museum.  It  seems 
probabh'that  renal  and  all  other  calculi  are  closely  related  to  the  salivary  calculi,  and 
that  the  eaiise  of  all  is  the  same. 


STUDIES   OF    SALIVARY    CALCULUS.  97 

Globulin  urea,  however,  has  something  of  a  literature.  I 
quote  the  following  from  a  pajoer  which  I  read  before  the 
Chicago  Dental  Society  in  January,  1912.* 

"In  general  medicine  it  seems  probable  that  much  useful 
information  of  importance  in  diagnosis  may  be  derived  from  a 
study  of  the  elimination  of  the  globulins.  How  and  where,  for 
the  most  part  will  be  determined  by  trial,  or  in  other  words,  a 
general  study  of  the  subject  as  it  appears  in  the  secretions,  and 
especially  in  the  excretions.  Already  globulinuria  has  a  con- 
siderable literature,  though  the  knowledge  of  it  seems  to  be 
rather  indefinite. 

''In  an  article  entitled  'Euglobulin  Reaction  in  Urine,'  by 
Arthur  R.  Elliott  of  Chicago,  in  the  Illinois  Medical  Journal 
for  November,  1911,  p.  520,  the  progress  of  this  literature  is 
cited.  There  is  also  a  discussion  of  the  difficulties  of  diagnosis 
between  albuminuria  and  euglobulinuria,  a  matter  which  is  very 
liable  to  confusion  by  the  close  resemblance  of  the  chemical 
reactions  of  the  globulins  to  albumin. 

''From  what  has  been  said  of  the  deposit  of  globulins  in 
the  form  of  agglutinin  of  calculus,  one  would  expect  the  appear- 
ance of  the  globulins  in  urine  to  be  transient.  This,  in  fact,  is 
what  seems  to  occur,  and  these  have  been  referred  to  as  inno- 
cent albuminurias.  This  article  by  Dr.  Elliott  is  worthy  of 
study  for  both  its  citation  of  authorities  and  its  discussion  of 
the  means  of  differential  diagnosis  now  known. 

"If  the  physician  could  command  the  time  to  learn  to  dis- 
tinguish readily  the  paroxysms  of  the  deposit  in  the  mouth,  he 
would  probably  find  a  coincidence  between  this  and  the  innocent 
albuminurias,  and  that  each  is  an  expression  of  the  same  sys- 
temic condition.  It  is  possible  that  the  careful  comparative 
study  of  the  saliva  and  urine  may  lead  to  clearer  definitions  and 
simplify  the  means  of  division  of  the  grave  and  the  innocent 
albuminurias. 

"But  are  these  repeated  paroxysms  of  elimination  of 
globulins  innocent  of  injury  to  health?  May  they  not  have  a 
causative  relation  to  some  grave  conditions,  or  a  harmful  rela- 
tion to  more  or  less  grave  conditions  now  not  fully  understood? 
It  opens  up  a  very  wide  field  for  question  and  investigation. 

"The  examination  of  the  saliva  and  other  secretions,  in 
conjunction  with  the  urine,  seems  to  be  demanded." 

Dr.  Henry  H.  Burchard  makes  a  quotation  in  his  paper  on 

*  "  Deposit  of  Salivary  Calculus,"  by  G.  V.  Black,  Dental  Kevicw,  Vol.  l2G,  1912, 
p.  337. 

11 


98  SPECIAL    DENTAL    PATHOLOGY. 

the  Origin  of  Salivary  Calculus,  Dental  Cosmos,  1895,  p.  828, 
from  a  conversation  Avitli  Dr.  E.  C.  Kirk,  in  which  Dr.  Kirk  is 
quoted  as  saying:  "I  believe  all  of  these  calculary  deposits  will 
he  found  to  belong  to  one  great  order.  That  salivary  calculi 
will  be  found  to  be  one  group  of  several  chemical  bodies  which 
are  formed  by  the  precipitation  of  lime  salts  in  colloid  media, 
and  this  is  the  common  factor  in  the  formation  of  calculi  in 
general.  That  about  a  nidus  these  substances  will  be  deposited, 
or  form  in  some  definite  manner ;  that  they  are  more  than  mere 
agglomerations  of  lime  salts  with  extraneous  matter;  that  they 
resemble  calco-globulin  more  than  they  do  mere  cemented  pre- 
cipitates, and  I  believe  all  calculi  will  have  a  family  similarity 
in  general  structure,  no  matter  in  what  part  of  the  body  they 
are  found." 

In  this  conversation,  as  reported  here.  Dr.  Kirk's  remarks 
were  probably  much  wiser  than  the  facts  then  known  would  seem 
to  justify.  The  sections  of  calculus  do  not  reveal  a  material 
that  seems  to  be  in  any  wise  akin  to  that  which  we  find  in  teeth, 
in  calco-spherites  in  the  dental  pulp,  or  in  the  phleboliths  found 
in  the  veins,  or  in  those  tiny  globules  thrown  down  from  albu- 
men solutions  which  contain  calcium  salts.  It  will  be  recog- 
nized that  this  material  appears  in  a  very  different  physical 
state  from  the  calco-spherites  deposited  from  colloid  material 
as  reported  by  Rainey  and  others.  In  the  consideration  of 
calcification  within  the  pulp  chamber  I  refer  to  the  very  inter- 
esting work  of  Rainey  and  Ord  and  show  two  illustrations  of 
nrtificially  formed  calco-spherites.     (See  Figures  338  and  339.) 

My  recent  search  for  the  actual  precipitate,  so  long  regarded 
as  the  basis  of  this  deposit,  has  failed  entirely  to  show  the 
occurrence  of  any  such  thing.  Neither  have  I  been  able  to 
isolate  a  precipitate  of  calcium  salts  by  any  means  I  have  yet 
tried.  When  I  have  dissolved  the  globulin,  the  calcium  has  also 
dissolved. 

Conclusion. 

I  am  slowly,  by  each  successive  step,  being  driven  to  the 
conclusion  that  the  thought  of  a  precipitate  of  calcium  salts 
from  the  saliva  so  long  held,  by  myself  and  others,  has  been  a 
myth.  It  seems  now  that  calculus  comes  into  the  mouth  as  a 
finely  divided  calco-globulin  which  collects  in  masses  on  hard 
substances  and  is  finally,  with  the  decomposition  of  much  of  the 
colloid  elements,  hardened  into  stony  calculus. 


INFLAMMATIONS   DUE    TO    SALIVARY    CALCULUS.  99 


GINGIVITIS  AND  PERICEMENTITIS  DUE  TO 
DEPOSITS  OF  SALIVARY  CALCULUS 

ILLUSTRATIONS:    FIGURES  114-170. 

The  injurious  effect  of  the  deposit  of  salivary  calculus  upon 
the  teeth  has  been  known  since  the  eariiest  historical  times. 
It  has  always  been  regarded  as  a  deposit  from  the  saliva.  The 
calculus  is  deposited  upon  the  teeth,  never  upon  the  mucous 
membranes  or  other  soft  parts.  It  is,  however,  the  soft  tissues 
which  are  injured  —  not  the  teeth  themselves,  except  as  they 
lose  their  soft  tissue  and  bony  investment.  Being  deposited 
upon  the  teeth,  the  calculus,  having  become  hard,  impinges  upon 
the  soft  tissues  and  causes  them  to  become  inflamed  and  red,  to 
bleed  easily,  and  to  become  involved  in  suppurative  processes. 

Gingivitis.     Beginnings  and  eaely  progress  of  deposit. 

The  place  of  first  deposit  is  usually  on  the  buccal  surfaces  of 
the  molars,  or  the  lingual  surfaces  of  the  lower  incisors.  In 
both  localities  the  deposit  is  close  to  the  margin,  or  crest,  of  the 
free  gingivae  and  appears  first  where  there  is  a  blunting  or  thick- 
ening of  the  free  gingivae,  forming  a  little  shelf  which  invites 
the  lodgment.  (See  Figure  144.)  In  many  cases,  however,  the 
deposit  spreads  from  these  points  and  may  include  all  of  the 
teeth.  When  the  deposit  begins  at  the  crest  of  the  gingivae,  the 
tendency  is  to  grow  in  thickness  and  to  spread  in  every  direction 
upon  any  parts  of  the  surface  of  the  tooth  or  teeth  that  are  not 
kept  clean  by  the  rubbing  of  food  over  them  in  mastication,  or 
l)y  artificial  cleaning.  As  this  goes  on,  from  month  to  month, 
the  deposit  impinges  more  and  more  upon  the  crests  of  the  free 
gingivae  and  causes  them  to  become  inflamed  and  bleed  easily, 
as  mentioned.  As  this  deposit  continues,  the  gingivae  become 
thickened  and  shortened  very  slowly.  This  greater  thiclmess 
of  the  tissue  gives  a  broader  shelf  for  the  lodgment  of  more 
calculus,  and  a  broader  covering  is  deposited  over  the  inflamed 
tissues.  In  studying  ground  sections  of  calculus  with  the  micro- 
scope, we  find  the  layers  of  deposit  as  it  occurs,  lapping  in  under 
the  thickened  lower  portion  of  the  deposit,  and  between  it  and 
the  remaining  soft  tissue.     This  is  fairly  well  shown  in  Figure 


100  SPECIAL   DENTAL   PATHOLOGY. 

163.  In  occasional  cases,  the  deposit  will  be  thicker  than  the 
thickness  of  the  gingivae,  and  will  overlap  the  lingual  or  labial 
surface  of  this  tissue.  This  is  most  frequently  seen  to  the 
lingual  of  the  lower  incisors,  but  may  occur  to  the  buccal  of  the 
molars,  or  elsewhere.  The  soft  tissue  will  often  remain  intact 
for  a  considerable  time  under  this  overlapping  calculus.  (See 
Figures  152, 153  and  154.) 

Suppuration.  The  irritation  of  the  investing  tissue,  caused 
by  the  presence  of  the  deposit,  and  the  covering  of  the  deposit 
itself,  offer  opportunity  for  collection  and  growth  of  the  bacteria 
of  the  mouth.  Therefore,  suppuration  of  the  soft  tissue,  in  con- 
tact with  the  deposit,  occurs  from  time  to  time,  destroying  parts 
of  the  tissue,  and  this  gives  opportunity  for  the  deposit  of  more 
calculus  in  the  space  gained.  This  goes  on,  very  slowly  as  the 
rule,  until  the  free  gingivas  are  destroyed  and  the  deeper  tissues 
are  reached.  Then  these  are  involved  by  the  suppurative  proc- 
ess as  cases  progress ;  the  bone  of  the  alveolar  process,  the  peri- 
dental membrane  and  the  gum  tissue  all  being  destroyed.  The 
products  of  suppuration  and  decomposition  will  often  make  the 
breath  very  foul. 

Pericementitis.     Destruction  of  the  deeper  tissues. 

If  not  artificially  removed,  the  encroachment  of  the  calculus 
goes  deeper  and  deeper,  involving  the  crest  of  the  alveolar  pro- 
cess and  the  adjacent  soft  tissue.  Indeed,  the  absorption  of 
bone  in  such  areas  of  inflamed  tissue  is  quickly  accomplished. 
(See  Figures  144,  145,  146  and  147.)  On  examining  this  tissue 
immediately  after  the  removal  of  the  calculus,  soft  granulation 
tissue  only  will  be  seen.  A  sharp  steel  probe  will,  however, 
show  but  a  slight  covering  of  granulation  tissue  over  the  short- 
ened and  apparently  thickened  stub  of  the  partly  absorbed  alveo- 
lar process.  In  this  way,  the  bony  alveolar  wall  is  destroyed, 
little  by  little,  from  month  to  month,  as  more  and  more  calculus 
is  added,  going  deeper  and  deeper  along  the  root  of  the  tooth  to 
which  it  clings.  All  of  the  investing  tissue,  soft  and  hard,  is 
destroyed  as  this  progresses.     (See  Figures  155  to  167.) 

Attachment  of  peridental  membrane  to  root  maintained 
TO  level  of  soft  tissue  remaining.  No  matter  what  the  extent  of 
the  injury,  the  attachment  of  the  peridental  membrane  to  the 
root  is  usually  maintained  to  the  level  of  the  soft  tissue  remain- 
ing. (See  Figures  144,  145,  146  and  147.)  Any  considerable 
accumulation  may  be  broken  away  from  the  tooth  with  suitable 
instruments,  and  give  a  clear  view  of  the  process  of  destruction. 


Fig.  H."). 


Fig.  144. 


Fig.   147. 


FlG.s.  144,  14;j,  14(i,  117.  Drawings  to  illusliatc  tlic  pr(.nr,.ssiv("  ilcstruct ion  of 
the  invfisting  lis.sues  caused  by  dejxisits  of  !-;ili\iiiy  ciilculus. 

Fig.  144  shows  a  slight  deposit  oii  the  liiigii:!!  siul'aci'  of  a  lower  ineisor  whieh 
iias  caused  a  gingivitis  only,  not  having  progressed  far  enough  to  involve  the  att:udi- 
nient  of  tlie  peridental   membrane  to  tin'  cementuni. 

Fig.  145  shows  a  similar  slight    deposit   on   tlir  Imcral   surface  of  an   ui>i>er  molar. 

Fig.  14(5  shows  a  more  extensive  accunudatiim  on  the  lingual  of  a  lower  ineisor 
than  tliat  shown  in  Figure  144.  It  will  be  noticed  that  the  gingival  line  of  the  tooth 
has  been  passed,  and  the  deposit  has  abnost  reached  the  crest  of  the  Ixuie. 

Fig.    147  shows  a  still  greater  destruction,   including  also   the   labial    tissues. 

In  all  of  those  it  Tvill  be  noticed  that  all  of  the  investing  tissues  —  gingiva', 
peridental  membrane,  bone  and  gum  —  are  destroyed  on  a  line  practically  horizontal  to 
the  long  axis  of  the  root,  and  pockets  alongside  the  rout  are  not  formed. 

*11 


Fig.   14S. 


Fig.   14V 


Fig. 


Fig.   l.'.i. 


Fig 


Fig.   l."):!. 


Fig.  l.J4. 


FiG.s.  14S.  149,  l.")i).  l."l.  Tcftli  (if  iioriiKil  fonii  sliowiug  extensive  deposits  of 
salivary  eaiciilus.     iSpociim-iis   fruiu  JSurthwesteni    I'liiversity  Dental   Museum. 

Figs.  152,  153,  154.  Lower  incisor  and  cuspids  with  deposits  of  salivary  calculus 
which  overlajiped  the  gum  tissue.  Specimens  from  Northwestern  University  Dental 
Museum. 


Fig.  155. 


Fig.  156. 


Fig.  15< 


Fig.  158. 


FlG.S.  15.'),  \r>i\.  Liiliial  :iih|  liiiu,|iil  vicwx  ,if  ii  lower  incisor  to.itli  ciitir.'lv 
enveloped,  except  purtiuii  of  crown,  by  (k'i)<)sit,  of  «ilivary  calculus.  No  portion 
whatever  of  the  root  can  be  seen.  Specimen  from  Xorthwestern  University  Dental 
Museum,  presented  l)y  Dr.  Herbert  S.  Merdock,  Sprinfjcr,  N.  M. 

Figs.  157,  158.  Labial  and  lingual  views  of  four  lower  incisors  the  roots  of 
which  are  enveloi)ed  by  dej)osits  of  salivary  calculus.  'I'iie  tuovements  of  these  teeth 
prevented  the  deposits  on  the  respective  roots  from  unitin<,r.  The  proximal  surfaces 
of  the  deposits  arc  worn  smooth  from  the  labio-iinyual  movement  of  the  teeth. 
Specimens  from    Xortli western    University  Dental   :\Iuseum. 

lib 


Fig.  159. 


Fig.  160. 


Fig.  161. 


Fig.  162. 


Figs.  159,  160.  Mesial  and  buccal  views  of  an  upper  second  molar  with  a  large 
deposit  of  salivary  calculus  which  did  not  destroy  the  tissue  immediately  adjacent  to 
the  root  above  the  ginjrival  line  of  the  tooth,  alliioutrh  only  a  little  was  spared.  This 
is  an  unusual  form  of  the  deposit.  Specimen  from  Northwestern  University  Dental 
Museum,  jiresented  by  Dr.  Arthur  B.  Freeman,  Chicago. 

FiG.S.  161.  162.  Two  views  of  an  upper  first  molar  witii  an  cnornHius  dejiosit  of 
salivary  calculus  attached.     Si)ecimen  from  Korthwestern  University  Dental  Museum. 


Fig.  163. 


Fig.  163.  Photoinicrograph  of  a  ground  section  of  a  tooth  with  a  deposit  of 
salivary  calculus  attached  to  the  root.  The  section  is  so  thin  that  the  structure  of 
the  dentin  IS  not  clear,  although  tho  j^ingival  portion  of  the  enamel  luav  be  seen  at 
the  top  of  the  illustnition.  Something  of  the  lamination  of  the  depos'it  as  it  was 
gradually  bu.lt  may  be  seen.  Specimen  ground  on  the  author's  special  grinding 
machine  descrdjed  in  the  Appendix  in  this  book. 


w 


ill 


i 


Fig.  164. 


Fig.  jo 


Fig.  166. 


Fit,.    Kj 


FiG.S.  164,  16."),  166,  11)7.  I  lliist  r;it  inns  sliowing  tlic  dcstnictii)ii  of  the  invosting 
tissues  by  deposits  of  salivary  c;ilculiis. 

Figs.  164  and  16.5  are  reproductions  of  radiogra])lis  sliowiny  extensive  destruction 
of  the  alveolar  process. 

Fig.  166  is  from  a  plaster  cast  of  a  case  in  uhicli  the  deposit  was  nearly  as 
extensive  on  the  labial  as  on  the  lingual  of  the  lower  incisors.  In  this  case  the  septal 
tissues  were  destroyed   by  the  use  of  a   wooden  toothpick,  rather  than  by  deposits. 

Fig.  167  is  from  a  skull.  This  shows  the  destruction  of  the  bone,  which  is 
especially  deep  between  the  central  incisors.  Specimen  from  Northwestern  University 
Dental  Museum. 


Fig.  16S. 


Fifi.  IC,9. 


Figs.  168,  ](J9.  An  \ippcr  and  a  lower  ])lat('  witli  very  heavy  <lci>iinils  ut'  salivary 
calculus.  On  both  of  these  the  greatest  thickness  of  tlie  aecuiiuihition  is  about  half 
an  inch.     iSpeciniens  from   rsorthwestern    University  JJental   Museum. 


Fifl.   170. 


Fig.  170.  A  ilciituro  sluiwiiig  a  dciiosit  laiil  ilnwii  in  a  sinylc  paroxysm.  A 
portion  of  the  soft  aecunuilation  was  dislodged  at  the  next  meal  after  the  deposit 
ocinirred,  as  shown  by  the  spot  above  the  position  of  the  second  molar. 


INFLAMMATIONS   DUE   TO    SALIVARY   CALCULUS.  101 

The  clean,  white  tooth  crown  will  stand  up  in  the  midst  of  an 
inflamed,  red  and  bleeding  tissue,  often  showing  the  naked  gingi- 
val line  where  formerly  the  soft  tissue  was  attached.  In  many- 
cases  all  of  both  the  free  gingivae  and  the  body  of  the  gingivae 
will  have  been  destroyed.  The  rule  is  that  pockets  are  not 
formed  alongside  the  roots,  although  some  detachment  may 
occur  in  the  more  advanced  cases.  This  is  markedly  different 
from  the  process  by  which  the  investing  tissues  are  destroyed 
in  chronic  suppurative  pericementitis,  as  will  be  described  later. 

Pain  and  soeeness.  During  the  early  progress  of  this  dis- 
ease there  is  little  or  no  pain.  The  teeth  may  become  more  or 
less  tender  in  mastication,  and  the  effective  work  of  the  teeth 
in  chewing  food,  also  the  cleaning  which  occurs  as  a  result  of 
vigorous  chewing,  will  be  diminished,  giving  additional  oppor- 
tunity for  the  accumulation  of  deposits  and  a  corresponding 
increase  of  the  inflammation.  It  is  only  toward  the  later  stages 
that  teeth  so  affected  begin  to  have  occasional  attacks  of  sore- 
ness. Usually  this  is  not  of  much  consequence  and  passes  away 
in  a  few  days.  This  occurs  at  irregular  intei^vals  and  grows 
worse  as  the  disease  progresses.  Toward  the  last  the  parox- 
ysms of  soreness  become  more  frequent  and  are  permanently 
relieved  only  by  the  loss  of  the  tooth.  When  we  realize  that 
these  periods  of  soreness  occur  with  tooth  after  tooth  over  long 
periods  of  time,  before  the  last  of  them  are  gone,  we  must  appre- 
ciate that  this  disease  has,  on  the  whole,  caused  a  large  measure 
of  physical  suffering. 

Teeth  become  loose  and  are  finally  lost.  As  the  alveolar 
process  is  destroyed  the  teeth  begin  to  have  much  motion  in  the 
remaining  part  of  their  alveoli.  This  loosening  may  occur  when 
the  bony  alveoli  are  but  little  more  than  half  destroyed.  This 
is  effected  by  the  absorption  of  that  part  of  the  bone  next  to  the 
peridental  membrane,  and  the  lengthening  and  softening  of  the 
fibers  connecting  the  teeth  with  the  bone.  The  fil)ers  are-  no 
longer  stretched  tightly  between  the  cementum  and  the  portion 
of  bony  alveolar  walls  that  are  left.  The  teeth  then  become  very 
loose  and  may  easily  be  moved  about;  yet  in  an  attempt  to 
extract  them,  they  are  very  firmly  held  by  the  elongated  fibers 
of  the  peridental  membrane,  as  by  so  many  small  but  strong 
ropes,  and  resist  actual  removal.  Finally,  however,  the  remain- 
ing attachment  is  so  slight  that  at  some  time,  when  a  very  loose 
tooth  is  particularly  sore  and  troublesome,  the  ])orson  will  suc- 
ceed in  picking  it  out  with  his  fingers.     In  this  long  and  tedious 


102  SPECIAL    DENTAL    PATHOLOGY. 

way,  running  from  five  to  thirty  years,  the  teeth  are  loosened 
and  one  by  one  are  lost,  until  finally  the  person  is  toothless. 

Menace  to  general  health.  But  this  is  not  all.  The  mass 
of  decomposing  pus  and  food  debris  in  and  about  the  deposits  of 
calculus,  and  in  the  suppurating  areas,  have  continuously  been 
the  home  of  masses  of  growing  bacteria  of  many  kinds,  sapro- 
phytic and  pathogenic,  which  are  often  a  serious  menace  to  the 
general  health.  This  may  be  the  most  serious  phase  of  the  con- 
dition, although  it  has  generallj^  received  little  consideration, 
either  by  patient,  dentist  or  physician.  The  relation  of  mouth 
infections  to  general  systemic  conditions  will  be  considered 
under  a  separate  heading. 

Variations  in  the  position  and  progress  or  the  deposit. 

I  have  described  above  the  picture  of  the  injury  resulting 
from  the  deposit  of  salivary  calculus  when  it  runs  its  course 
without  interference,  attacking  all  of  the  teeth  together,  or  in 
fairly  close  succession.  This  occurs  only  in  the  minority  of 
cases,  which  have  no  treatment.  AVhile  the  deposit  on  the  lower 
incisors  and  cuspids  is  seen  most  frequently  on  the  lingual  sur- 
faces, a  beginning  may  be  made  upon  the  labial  surfaces  also. 
(See  Figures  144  to  147.)  Often  it  occurs  that  the  progress  is 
made  mostly  upon  the  lingual  and  labial  surfaces,  leaving  for 
a  time  the  septal  tissue  standing  between  the  teeth  almost 
untouched.  Finally  the  calculus  may  close  in  upon  the  lateral 
sides  of  these  septi  and  this  tissue  will  be  destroyed.  (See 
Figures  148,  149  and  150.)  In  the  biscupid  and  molar  region, 
while  the  principal  deposit  is  on  the  buccal  surfaces,  the  lingual 
may  become  involved,  and  subsequently  the  septal  gingivae  may 
be  destroyed.  The  lower  bicuspids  and  molars  are  usually  not 
quite  so  extensively  involved  as  the  corresponding  upper  teeth. 

Deposit  usually  confined  to  certain  teeth.  Very  gener- 
ally the  deposit  will  be  confined  to,  or  a  greater  amount  of 
deposit  will  occur  on,  some  certain  teeth.  Others  will  escape 
for  a  time,  or  pennanently.  Then  teeth  will  be  lost  from  this 
cause  only  in  special  regions.  These  are  most  likely  to  be  the 
molars,  upper  and  lower,  and  the  lower  incisors,  sometimes  the 
one  and  sometimes  the  other,  or  both  together.  Again,  some 
particular  tooth,  or  teeth,  other  than  the  groups  named,  may  be 
attacked. 

conditions  contributing  to  occurrence  of  deposit. 
1.     Calco-globulin  must  be  brought  to  the  mouth  by  the 
saliva  from  the  salivary  glands. 


INFLAMMATIONS    DUE    TO    SALIVAEY    CALCULUS.  103 

2.  Deposits  usually  occur  first  on  teeth  near  the  opening 
of  the  ducts  from  the  parotid  or  the  submaxillary  and  sublingual 
glands.  Taking  all  cases  together,  these  are  the  places  where 
the  general  bulk  of  the  calculus  is  deposited. 

3.  Points  of  depression  in  the  gingivae  of  certain  regions 
or  about  certain  teeth,  the  thickening  of  the  crests  of  the  gingivae 
from  any  cause,  such  as  mechanical  injuries,  previous  injuries 
by  calculus,  etc.,  may  become  places  of  deposit  because  of  the 
malform. 

Form  which  gives  opportunity  for  initial  deposit.  The 
controlling  factor  then  is  form  which  gives  opportunity.  If  we 
suppose  that  calculus  enters  the  mouth  with  the  saliva  and  is 
immediately  ready  for  deposit,  the  nearest  teeth  would  receive 
it.  This  is  the  general  rule,  as  has  been  stated.  But  the  teeth 
of  this  locality,  and  their  gingivae,  may  be  of  excellent  form,  and 
will  not  readily  receive  the  deposit,  or  the  soft  deposit  may  be 
removed  in  the  act  of  chewing  food  at  the  next  meal.  Then 
deposits  may  or  may  not  occur  elsewhere,  dejjending  upon  form 
which  will  favor  a  lodgment. 

The  position  of  the  deposit  is  determined  by  some  peculiarity 
of  form  which  usually  will,  on  close  study,  be  found  to  furnish  a 
place  for  the  initial  deposit  and  shelter  it  from  removal  during 
mastication.  This  may  be  an  irregularity  in  the  shape  or  the 
position  of  the  teeth  attacked,  or  of  their  gingivae.  To  produce 
such  a  result  the  deviation  from  normal  form  need  not  be  great, 
but  just  a  slight  depression  of  the  crest  of  the  free  gingivae  and 
a  thickening  of  its  margin,  which  will  furnish  a  favorable  place 
for  sheltering  the  deposit. 

I  have  had  occasion  to  study  this  matter  very  closely  in 
forming  traps  for  the  collection  of  deposits  for  microscopic 
study.  These  traps,  as  has  been  mentioned,  consist  of  little  gold 
frames  fastened  with  screws  to  hold  microscopical  cover-glasses 
in  selected  positions  on  a  plate  (See  Figure  122.)  Once  I  made 
a  very  nice  trap  for  a  new  plate,  beveling  the  angles  and  care- 
fully polishing  them  down  to  the  glass,  obliterating  the  angle  of 
meeting  of  the  gold  and  the  glass,  as  nearly  as  possible.  No 
deposit  occurred  on  the  cover-glass,  although  the  plate  was  worn 
during  a  number  of  paroxysms  of  deposit.  I  was  compelled  to 
restore  the  angle  in  order  to  get  a  deposit  on  the  glass.  An 
angle  or  corner,  or  roughening  of  the  margins  of  the  gold  frame, 
is  necessary  to  give  the  opportunity  for  the  initial  deposit. 
With  such  a  place  of  beginning,  tlio  deposit  will  build  out  over 
the  glass. 


104  SPECIAL   DENTAL   PATHOLOGY. 

Forms  of  artificial  dentures  to  avoid  deposits.  This 
condition  should  cause  us  to  make  a  study  of  the  forms  of  artifi- 
cial dentures  with  respect  to  deposits  of  calculus.  It  is  quite 
possible  to  so  make  and  finish  a  plate  that  no  calculus  will 
adhere  to  it  anywhere.  This  requires,  first,  that  all  irregulari- 
ties of  surface  be  avoided;  and  second,  that  every  part  of  the 
plate  be  finely  polished.  Every  part  must  be  given  as  nearly  a 
regular  surface  as  possible.  All  of  the  embrasures  between  the 
curves  of  the  teeth,  as  these  spread  from  the  contact  points, 
should  be  filled  with  gingivaa  practically  as  full  as  these  are 
in  the  best  natural  forms.  The  crests  of  the  gingiva^  should  be 
reduced  to  a  fine  knife  edge  where  the  rubber  laps  onto  the  teeth. 
This  will  make  a  surface  of  rubber  or  of  gold  so  smooth  that  it 
will  not  receive  agglutinin  and,  as  a  consequence,  no  calculus 
will  be  deposited  upon  it.  To  keep  it  so  in  general  usage,  is  of 
course  another  question,  but  it  may  be  done  by  frequent  repol- 
ishing.  A  full  upper  denture  is  shown  in  Figure  168,  and  a  par- 
tial denture  in  Figure  169,  both  of  which  have  very  large 
deposits. 

Influence  of  mastication  in  preventing  deposits.  Occa- 
sionally, the  influence  of  the  chewing  of  food  in  preventing  lodg- 
ments is  strongly  accentuated  in  cases  in  which  an  exposed  pulp 
causes  pain  in  chewing  food  upon  one  side.  This  leads  the 
person  to  do  all  of  the  work  of  mastication  upon  the  teeth  of  the 
opposite  side.  Then  the  teeth  of  the  unused  side  will  receive 
the  deposits  of  calculus.  In  such  cases  I  have  seen  the  teeth  of 
the  unused  side  thickly  encrusted  with  calculus  on  all  surfaces, 
except  some  portions  of  the  occlusal  surfaces  which  made  con- 
tact with  occluding  teeth,  wliile  the  teeth  of  the  used  side 
received  very  little  or  no  deposit,  and  their  investing  tissues 
presented  a  healthy  appearance. 

A  similar  condition  is  occasionally  seen  on  artificial  den- 
tures. If  one  side  is  more  convenient  to  use  than  the  other,  the 
unused  side  will  receive  and  hold  deposits,  while  these  will  be 
prevented  from  accumulating  on  the  used  side.  Sometimes  the 
upper  molar  teeth  are  strongly  inclined  buccal ly,  and  the  buccal 
margins  stand  out  over  the  buccal  surface  of  the  lower  molars. 
This  prevents  the  rubbing  of  the  buccal  surfaces  of  the  upper 
molars  by  food  in  the  act  of  chewing,  and  makes  these  surfaces 
favorable  places  for  lodgments. 


INFLAMMATIONS   DUE    TO    SALIVARY    CALCULUS.  105 


TREATMENT  OF  GINGIVITIS  AND  PERICEMEN- 
TITIS CAUSED  BY  DEPOSITS  OF 
SALIVARY  CALCULUS. 

ILLUSTRATIONS:    FIGURES  171-178. 

The  treatment  of  inflammations  caused  by  deposits  of 
salivary  calculus  should  consist:  first,  of  the  thorough  removal 
of  the  deposits  and  the  care  of  the  tissues  by  the  dentist  until 
the  inflammation  has  subsided;  second,  the  training  of  the 
patient  in  the  means  of  preventing  a  redeposit,  gradually  leav- 
ing to  the  patient  the  principal  care  of  the  case;  third,  subse- 
quent examinations  at  stated  intervals  to  criticize  the  care  by 
the  patient  and  remove  any  deposits  which  may  have  occurred. 
It  has  been  sufficiently  demonstrated  that  this  plan  of  treatment 
is  dependable. 

The  removal  of  salivary  calculus  seems  to  have  been 
regarded  as  a  thankless  and  disagreeable  operation  from  far 
back  in  the  history  of  dentistry.  This  has  been  from  two  causes. 
First,  dentists  have  had  no  confidence  in  the  real  efficacy  of  the 
operation  for  more  than  a  very  temporary  benefit ;  second,  they 
have  not  understood  the  nature  of  the  deposit,  and  while  they 
have  recommended  to  their  patients  that  they  keep  it  off  their 
teeth,  they  have  generally  done  so  in  a  way  which  showed  an 
attitude  of  uncertainty  as  to  results.  There  has  generally  been 
no  instruction  as  to  how  or  when  to  clean  the  teeth,  further  than 
to  direct  that  the  brush  be  used.  The  movements  of  the  brush 
in  cleaning  have  only  recently  received  anything  like  standardi- 
zation. Under  these  conditions  it  is  not  much  wonder  that 
patients  have  not  succeeded  in  preventing  deposits. 

With  the  discoveries  which  my  own  experimental  observa- 
tions of  the  last  few  years  have  disclosed,  all  of  this  should  be 
changed.  Indeed,  previous  to  undertaking  my  recent  investiga- 
tions, so  far  as  I  had  seen  results  from  the  persistent  plans  of 
treatment  of  such  cases  by  cleaning  operations  pure  and  simple, 
it  had  become  fixed  in  my  mind  that  the  successful  treatment  of 
inflammations  of  the  gingiv.T,  caused  by  de]iosits  of  salivary 
calculus,  offered  but  one  real  difficulty.  That  difficulty  was  to 
convince  the  patient  tliat  a.  permanent  cure  could  })e  made  by  the 


106  SPECIAL    DENTAL   PATHOLOGY. 

cleaning  method,  and  the  calculus  prevented  from  lodgment 
again  in  harmful  quantities.  What  is  now  known  of  the  nature 
of  the  deposit  fully  warrants  the  statement  that  this  may  be 
realized,  if  the  patient  will  exercise  reasonable  diligence  in  the 
daily  cleaning  of  the  mouth  in  the  manner  which  I  will  describe. 
Under  these  conditions  both  the  dentist  and  the  patient  may 
undertake  this  work  with  the  feeling  that  it  is  well  worth  the 
time  and  the  energy  put  into  it. 

Removal  of  deposits  and  caee  of  tissues  by  the  dentist. 

The  instrumental  removal  of  the  ordinary  deposits  of  hard- 
ened salivary  calculus,  when  taken  in  time,  really  offers  very  few 
difficulties.  The  deposit  is  always  in  sight;  if  not  directly,  it 
may  be  seen  indirectly  with  the  aid  of  the  mouth-mirror.  It  is 
practically  never  buried  under  the  soft  tissues,  nor  covered  up. 
AVliile  this  statement  is  true,  I  have  seen  a  very  few  cases  in 
which  some  salivary  calculus  extended  under  the  free  gingivae. 
I  have  also  seen  the  gingivae  when  much  inflamed  and  swollen, 
turned  outward  from  the  tooth,  creating  an  open  pocket  which 
might  become  filled  with  calculus.  Such  cases  are  much  too  rare 
to  enter  into  any  calculation  for  general  cleaning  processes. 
However,  their  possible  existence  should  not  be  overlooked. 

It  should  be  understood  that  deep  pockets  along  the  sides  of 
the  roots  of  teeth  do  not  occur  as  a  result  of  deposits  of  salivary 
calculus,  and  they  are  not  therefore  to  be  considered  under  this 
heading. 

Previous  to  the  removal  of  the  deposits,  and  as  a  part  of 
the  examination  of  the  mouth,  a  careful  record  should  be  made 
of  each  surface  of  each  tooth  upon  which  a  deposit  is  found. 
A  simple  and  exact  method  of  doing  this  will  be  presented  later. 
This  record  should  be  the  foundation  upon  which  the  future 
conduct  of  the  case  should  rest.  A  definite  record  of  the  condi- 
tion of  the  mouth  as  to  deposits  should  be  the  guide  for  the 
after  care,  the  training  required  by  the  patient  and  the  fre- 
quency of  subsequent  examinations.  It  is  of  the  greatest  impor- 
tance that  the  patient  shall  in  the  beginning  be  impressed,  not 
only  with  the  serious  final  results  of  neglect,  but  with  the  fact 
that  there  is  a  definite  and  dependable  system  of  handling  such 
cases. 

Instruments  and  instrumentation.  There  is  no  more 
simple  operation  in  the  dentist's  field  than  the  removal  of 
deposits  of  salivary  calculus.  Since  the  deposit  is  practically 
always  upon  the  exposed  surfaces  of  the  teeth  it  is  easily  seen 


INFLAMMATIONS    DUE    TO    SALIVARY    CALCULUS.  107 

either  by  direct  vision  or  with  a  mouth-mirror.  A  very  simple 
set  of  scalers  is  sufficient.  Years  ago  these  instruments  were 
generally  much  larger  and  stronger  than  those  of  to-day, 
because  of  the  frequent  necessity  of  removing  heavy  deposits. 
It  was  not  uncommon  for  the  dentist  to  use  a  large  chisel,  held 
with  the  edge  against  the  deposit,  while  the  assistant  struck  it  a 
sharp  blow  with  the  mallet.  As  our  people  have  learned  to 
better  control  the  deposit  by  brushing,  the  sizes  of  the  scalers 
used  for  its  removal  have  become  gradually  smaller. 

I  present  herewith  a  set  of  six  scalers.  A  similar  set  may 
be  secured  from  any  dealer  in  dental  instruments.  ( See  Figure 
171.)  These  consist  of  one  pair  of  pull  instruments,  one  pair 
of  push  instruments,  a  sickle  and  a  cleoid.  These  are  all  that 
are  necessary  for  the  removal  of  the  bulk  of  the  deposits.  Their 
use  should  be  followed  by  selected  instruments  from  the  set  of 
scalers  for  the  removal  of  serumal  deposits,  which  are  smaller 
and  are  better  for  removing  finer  particles  which  may  have  been 
left  by  the  larger  instruments.  These  are  shown  in  Figure  186. 
In  cases  in  which  the  deposit  is  light,  the  smaller  scalers  will 
often  be  preferred  to  the  larger  instruments. 

The  pull  scalers  should  usually  be  used  first  for  removing 
the  bulk  of  the  deposit  from  the  lingual  surfaces  of  the  lower 
front  teeth.  These  may  be  followed  by  the  cleoid  or  sickle,  or 
both,  to  remove  deposits  about  the  angles  or  on  the  proximal 
surfaces.  Oftentimes,  heavy  deposits  on  the  lingual  of  the 
lower  incisors,  particularly  if  they  extend  around  the  proximal 
angles,  may  be  removed  very  nicely  by  using  the  pair  of  push 
scalers,  the  blade  being  applied  with  its  edge  part  way  around 
the  angle  into  the  embrasure. 

For  the  molars,  both  upper  and  lower,  deposits  of  salivary 
calculus  may  be  removed  from  most  buccal,  lingual  and  distal 
surfaces  with  the  pull  scalers.  The  cleoid  or  sickle  may  also  be 
used  about  the  distal  angles  of  these  teeth.  The  push  scalers 
will  often  be  more  convenient  for  proximal  surfaces,  the  blade 
being  used  through  the  space  from  buccal  to  lingual. 

This  operation  involves  sufficient  practice  in  the  adaptation 
of  the  instruments  to  gain  confidence  and  reasonable  skill  in 
management.  Both  the  manner  of  handling  the  instrument, 
and  the  character  of  the  resistance  of  the  material  to  be  removed, 
must  be  learned  by  actual  observation  and  experience.  One* 
should  aim  at  the  first  movement,  to  place  tlie  edge  of  the  pull 
instrument  between  the  gum  and  ihe  giugival  margin  of  the 
calculus,  and  pull  toward  the  occlusal  of  the  tooth,  until  force 


108  SPECIAL   DENTAL    PATHOLOGY. 

enough  is  applied  to  break  the  calculus  away.  If  at  one  time  too 
much  is  caught  to  be  broken  away  witli  the  use  of  reasonable 
force,  the  position  of  the  instrument  should  be  changed  so  as  to 
remove  a  smaller  portion  at  first.  In  using  the  push  instru- 
ment, care  should  be  exercised  to  have  a  sufficiently  good  finger 
rest  so  that  the  instrument  may  be  prevented  from  plunging 
forward  with  the  sudden  breaking  away  of  the  deposit  and 
injuring  the  near-by  gum  or  other  soft  tissue. 

In  connection  with  the  scaling  operation,  the  dentist  or  his 
assistant  should  frequently  flood  the  mouth  with  a  jet  of  warm 
water  from  a  large  rubber  bulb  syringe.  This  not  only  keeps 
the  field  of  operation  clear,  but  is  very  pleasant  and  comforting 
to  the  inflamed  tissues.  A  water-tank  for  this  especial  purpose 
is  shown  in  Figure  172.  This  is  equipped  with  an  electric  ther- 
mostat (Figures  173,  174  and  175),  which  keeps  the  temperature 
of  the  water  a  little  above  the  body  temperature.  The  style  of 
syringe  which  I  prefer  is  shown  in  Figure  176.  Great  care  as 
to  wounding  the  soft  tissues  will  do  much  to  prevent  flooding  the 
area  with  blood.  If  much  inflamed,  the  gums  bleed  very  freely. 
In  such  cases,  the  bulk  of  the  deposits  should  be  removed  at  the 
first  sitting,  and  the  patient  should  be  dismissed  for  a  day  or 
two.  At  the  next  sitting,  the  inflammation  should  be  much 
reduced,  and  a  more  thorough  operation  may  be  performed. 
In  such  cases  in  which  there  is  much  calculus  widely  scattered 
among  the  teeth,  the  operation  is  tedious.  Both  the  patient  and 
the  operator  may  tire  out.  In  such  a  case  the  operation  may  be 
adjourned  from  time  to  time  until  completed.  One  should  not 
be  in  a  hurry  to  get  through. 

Following  the  removal  of  the  deposit,  at  the  same  sitting, 
or  at  a  subsequent  sitting,  if  there  is  much  inflammation  of  the 
adjacent  soft  tissue,  the  surfaces  from  which  the  deposits  have 
])een  removed  should  be  carefully  polished  with  powdered 
pumice  and  water,  using  rubber  or  wooden  disks,  or  points  of 
various  shapes,  also  orange-wood  sticks  in  the  hand.  These 
should  all  be  used  with  great  care  not  to  injure  the  gingivae. 
In  some  positions,  and  particularly  in  cases  in  which  the  inter- 
proximal tissue  has  been  more  or  less  destroyed,  polishing  tapes 
may  be  used.  It  should  be  remembered  that  the  normal  attach- 
ment of  the  gingivae  on  the  proximal  surfaces  of  the  incisors  is 
very  much  closer  to  the  incisal  edge  than  on  lingual  or  labial 
surfaces,  and  there  is  danger  of  cutting  away  the  proximal 
attachment  in  the  careless  use  of  strips.  In  any  position,  strips 
should  be  used  with  the  greatest  care. 


Fig.  171. 


Fig.  171.  A  sot  of  six  scalers  for  removing  deposits  of  salivary  calculus.  This 
set  consists  of  two  pull  instruments,  two  push  instruments,  a  ch'oid  form,  and  a  sickle 
form.  If  the  deposits  are  slight,  the  set  of  instruments  sliown  in  I'^igiin'  Isc.  will  be 
preferable. 


*12 


Fig.  17-2. 


Fig.  172.  Water  tank  for  di'iitist's  office.  Tliis  tank  is  kept  full  of  filtered  water 
and  the  temperature  is  regulated  by  an  electric  thermostat.  The  faucet  to  the  left 
is  in  a  pipe  leading  from  the  filter.  The  valve  may  be  adjusted  so  that  the  water 
ilrips  slowly.  The  level  in  the  tank  is  regulated  by  the  overflow  pipe  which  empties 
into  a  waste  pipe.  Heat  is  furnished  by  a  16  c.  p.  carbon  filament  lamp  attached  to 
the  porcelain  in  the  center  on  top  of  the  tank.  The  lamp  is  enclosed  in  a  thin  copper 
well  which  is  fastened  to  the  lid  of  the  tank,  so  that  the  well  is  dry.  A  little  red 
bull's-eye,  just  in  front  of  the  ])orcelain  lamp  supjiort,  shows  when  the  lamp  is  on 
and  off.  The  thermostat  projecting  from  the  top  of  the  tank  near  the  left  end  is 
described  in  Figures  173,  174,  175.  A  thermometer  to  the  right  has  its  bulb  in  the 
water.  Two  rubber  bulb  syringes  fit  into  "  cups  "  so  that  the  ends  of  the  nozzles 
are  in  the  water.  The  tank  is  not  "  connected  "  with  the  plumbing,  and  may  be  lifted 
off  two  wall  brackets  for  cleaning. 

The  water  is  kept  at  10,3°  in  the  tank,  so  that  it  will  be  about  body  tem- 
perature when  the  water  reaches  the  mouth.  It  is  very  comforting  to  the  soft  tissues 
to  flush  the  mouth  frequently  during  scaling  operations,  and  during  cavity  prepara- 
tions as  well.  The  temperature  may  be  kept  so  close  to  the  body  temperature  that 
there  will  be  no  pain  when  washing  out  the  most  sensitive  cavities. 


Fig.  174. 

Figs.  173,  174,  175.  Electric  thermostat  designcfl  by  the  author  for  bacterio- 
logical and  other  dry  ovens,  and  for  water  tanks,  as  illustrate<l   in    Figure    172. 

Fig.  173  shows  the  instrument  enclosed  in  a  brass  case  so  that  it  may  be  immersed 
in  water.  The  wires  are  attached.  The  connection  of  the  wires  with  the  lamp  is 
shown  in  Figure  172. 

Figs.  174  and  175  show  the  thermostat.  The  brass  rod  holds  the  lower  end 
stationary.  Attached  to  this  rod  at  its  lower  end  is  a  double  metal  ribbon  consisting 
of  a  thin  ribbon  of  aluminum  and  one  of  steel  riveted  together.  The  aluminum 
expands  more  rapidly  than  the  steel,  consequently  the  ribbon  is  bent  with  the  con- 
cavity on  the  steel  side  as  the  heat  increases.  A  platinum  jioiut  on  the  u|>p('r  eixl 
makes  and  breaks  the  current  with  another  point,  which  is  adjustable  witli  a  lluuub- 
screw.  (See  Figure  171.)  T.y  tliis  arrangement  the  lainit  burns  wlieuever  tlie  tem- 
perature drops  below  thai  for  which  the  thermostat  is  sri  ;in.l  is  turiird  otV  wlini 
it  rises  above. 


Fig.  1 7().  Tlir  larf;o  riihhor  hull)  syringe  used  for  rinsing  the  ludutli  mjhI  for 
irrigation  for  all  purposes  in  the  mouth.  Illustration  actual  size.  This  syringe  holds 
two  ounces.  As  these  arc  received  from  the  supply  houses,  the  hole  in  the  end  of  the 
nozzle  is  too  small.  Enough  shouM  be  cut  from  the  end  to  give  an  opening  about 
1..5  mm.  inside  measurement.  With  such  a  syringe  the  mouth  may  be  quite  thor- 
oughly cleansed  of  mucus,  blood  and  debris  in  scaling  operations.  In  the  preparation 
of  cavities  it  is  imi)ortant  to  have  plenty  of  water  to  remove  most  of  the  mucus. 


INFLAMMATIONS   DUE   TO    SALIVARY    CALCULUS.  109 

Caee  of  tissues  by  the  dentist.  During  the  time  of  remov- 
ing calculus,  and  in  the  more  severe  cases  for  a  brief  period 
afterward,  the  dentist  should  look  after  the  cleaning  of  the 
teeth  himself,  for  it  is  fair  to  presume  that  a  patient  who  has 
badly  inflamed  gums  from  this  cause,  has  not  been  in  the  habit 
of  brushing  the  teeth  properly,  and  could  not  be  expected  to  do 
so  until  after  the  inflammation  shall  have  subsided.  In  fact  the 
use  of  the  toothbrush  is  contraindicated  at  this  time. 

In  addition  to  the  removal  of  the  deposits,  the  treatment  up 
to  the  time  when  the  inflammation  shall  have  subsided,  should 
consist  of  the  most  thorough  mechanical  cleansing  with  the  least 
possible  irritation.  This  may  be  best  accomplished  by  using 
warm  i^hysiological  salt  solution  in  a  rubber  bulb  syringe.  This 
will  remove  all  accumulations  of  micro-organisms,  their  prod- 
ucts and  other  debris  from  the  surface  of  the  inflamed  areas 
and  thus  advance  the  healing  process.  A  half-dozen  or  more 
syringefuls  of  the  solution  should  be  forced  through  the  inter- 
proximal spaces,  under  and  about  the  gingiva^,  giving  especial 
attention  to  the  inflamed  areas.  The  sense  of  comfort  to  the 
patient  as  a  result  of  several  such  treatments  will  often  be  suffi- 
cient to  induce  the  patient  to  become  an  enthusiastic  user  of  the 
syringe  in  the  subsequent  care  of  the  mouth.  The  preparation 
of  the  salt  solution  is  much  simplified  by  the  use  of  sodium 
chloride  tablets,  prepared  for  the  purpose.     (See  Figure  177.) 

For  reasons  which  will  be  fully  mentioned  later,  no  anti- 
septics should  be  used.  It  should  be  recognized  that  the  treat- 
ment of  this  condition,  with  our  present  knowledge  of  it,  is 
purely  mechanical.  Micro-organisms  have  no  influence  in  caus- 
ing the  deposit  of  salivary  calculus.  They  do,  however,  grow 
luxuriantly  in  'these  deposits,  and  have  the  principal  part  in 
causing  the  inflammation  and  suppuration  of  the  soft  tissues. 
Careful  observations,  over  long  periods  of  time,  involving  large 
numbers  of  cases,  show  unmistakably  that  if  harbor  points  and 
masses  of  accumulations  are  removed  at  stated  intervals,  the 
soft  tissues  will  not  be  seriously  injured.  It  has  been  well 
known  for  years  that  we  can  not  sterilize  the  mouth  for  even  an 
hour,  nor  in  any  way  prevent  micro-organisms  from  growing 
there  in  case  of  lesions  in  the  mouth  tissues.  If  we  will  prevent 
accumulations  of  growth  of  micro-organisms  and  their  products 
upon  the  tissues,  the  phagocytes  will  be  active  in  attacking  any 
organisms  which  may  have  entered  the  tissues.  The  chemotac- 
tic  action  of  antiseptics  causes  the  phagocytes  to  withdraw; 
antiseptics  are  therefore  contraindicated. 


110  special  dental  pathology. 

Cake  by  the  patient. 

As  soon  as  the  inflammation  subsides  the  patient  should  be 
trained  in  doing  the  necessary  cleaning.  This  is  just  as  impor- 
tant as  the  removal  of  calculus.  The  dentist  should  avail  him- 
self of  every  opportunity  to  impress  this  fact.  Indeed  this  is 
the  large  part,  without  which  the  operation  can  be  of  only 
temporary  benefit.  There  is  nothing  permanent  in  the  simple 
removal  of  calculus.  Permanence  must  depend  upon  the  daily 
habit  of  the  patient.  It  must  become  a  part  of  the  patient's 
care  of  his  or  her  person.  Every  one  should  remember  that 
distinctly.  It  is  the  dentist's  duty  to  do  this  teaching,  and  in 
no  such  case  to  discharge  the  patient  as  well.  Do  what  one  will, 
with  our  present  knowledge  of  this  subject,  the  tendency  will 
remain  for  the  deposit  to  recur.  We  may  train  certain  patients 
to  be  so  careful  in  their  eating  that  no  deposits  will  occur  and 
at  the  same  time  do  much  to  improve  the  patient's  general  health 
and  vigor.  That,  however,  is  not  fully  dependable.  It  is  much 
easier  for  patients  to  control  the  matter  by  cleaning  than  by 
care  in  eating,  and  this  is,  therefore,  the  safer  treatment.  As 
a  matter  of  fact  both  should  go  together.  We  Imow  full  well 
that  soft  calculus  remaining  on  the  teeth  only  a  few  hours  does 
no  appreciable  harm. 

In  many  of  these  cases  it  is  difficult  to  say  at  what  point 
the  dentist  should  transfer  the  care  of  the  case  to  the  patient. 
In  all  cases  in  which  there  is  any  marked  inflammation  of  the 
investing  tissues,  the  case  should,  as  already  mentioned,  be  kept 
under  observation  until  the  inflammation  has  subsided  suffi- 
ciently to  permit  the  free  use  of  the  brush  and  syringe  by  the 
patient.  In  the  majority  of  cases,  even  those  in  which  there  is 
much  inflammation,  the  improvement  is  rapid.  Within  a  few 
days  the  patient  should  usually  undertake  the  cleaning  opera- 
tions.    Then  the  visits  to  the  dentist  may  be  at  greater  intervals. 

Some  patients  will  be  very  willing  to  do  their  part,  but  be 
very  awkward  at  first,  and  will  need  watchful  care  and  instruc- 
tion. Others  will  take  it  up  easily  from  the  start.  The  most 
difficult  thing  is  to  instil  the  idea  of  perfect  regularity  in  doing 
this  cleaning.  Even  with  willing  patients,  it  is  difficult  to 
accomplish  this,  although  it  is  absolutely  essential  to  success. 

As  a  first  step  in  the  training  of  the  patient,  the  dentist 
should  point  out  the  places  where  the  deposit  has  occurred  and 
explain  how  necessary  it  is  that  these  areas  be  brushed  at  least 
twice  daily,  if  redeposits  are  to  be  prevented.  The  patient 
should  understand  that  the  deposit  is  soft  at  first  and  remains  so 


INFLAMMATIONS   DUE    TO    SALIVAKY    CALCULUS.  Ill 

for  twelve  hours  or  more,  and  that  during  this  time  it  may  be 
easily  removed  with  a  brush  and  plain  water.  Absolutely  noth- 
ing else  is  required.  Particular  emphasis  should  be  laid  on  the 
fact  that  to  miss  the  brushing  of  these  areas  a  single  time  may 
mean  that  there  will  be  sufficient  hardening  of  a  slight  amount  so 
that  it  can  not  be  removed  with  the  brush,  also  that  this  slight 
deposit,  by  its  roughness,  serves  to  attract  and  hold  future 
deposits. 

The  dentist  should  see  to  it  that  the  patient  has  proper 
brushes,  and  a  syringe,  and  he  should  by  using  his  brush  in  his 
own  mouth  demonstrate  the  positions  and  movements  neces- 
sary. He  should,  in  many  cases,  require  patients  to  bring  their 
brushes  to  the  office,  observe  their  use  of  them,  and  instruct 
them  in  the  proper  methods. 

The  use  of  the  rubber  bulb  syringe  by  the  patient  as  a  part 
of  the  daily  routine  of  cleaning  the  mouth  will  be  appreciated 
by  most  patients  when  they  have  once  learned  its  use  and  the 
sense  of  comfort  which  it  gives.  While  deposits  of  salivary 
calculus  may  be  prevented  with  nothing  else  than  the  brush  and 
water,  the  gingivae  may  be  kept  in  better  condition  by  the  use 
of  the  syringe  and  thereby  reduce  the  opportunity  for  future 
deposits. 

A  detailed  statement  of  the  technic  of  using  tooth-brushes 
and  the  syringe  will  be  presented  under  the  heading  of  Mouth 
Hygiene. 

From  what  has  been  said,  it  should  be  quite  obvious  that 
tooth-powders,  tooth-pastes  and  mouth  washes  are  not  indi- 
cated in  the  treatment  of  these  inflammatory  conditions. 

Subsequent  examinations. 

Every  patient  for  whom  deposits  have  been  removed  should 
be  impressed  with  the  importance  of  returning  at  stated  inter- 
vals for  inspection  and  the  correction  of  errors  in  cleaning. 
The  frequency  of  such  visits  should  depend  upon  the  case,  and 
the  earnestness  of  the  effort  on  the  part  of  the  patient.  In 
cases  in  which  there  has  been  serious  neglect,  the  patient  should 
be  requested  to  return  within  a  month.  If  it  is  then  apparent 
that  the  cleaning  is  being  well  done,  a  longer  period  may  be 
given  before  the  next  visit.  For  persons  who  have  become  well 
trained  and  are  in  earnest  in  the  care  of  their  mouths,  appoint- 
ments every  six  months  are  sufficiently  frequent,  and  for  many 
such  people,  little  or  no  deposit  will  be  found  even  then. 

As  will  be  presented  more  in  detail  later,  the  dentist  should 


112  SPECIAL   DENTAL   PATHOLOGY. 

have  a  reliable  plan  of  arranging  for  subsequent  examinations. 
The  patient  should  be  informed  of  the  desirability  of  an  exam- 
ination at  a  stated  time,  and  the  dentist  should  offer  to  take  the 
responsil)ility  of  notifying  the  patient  when  the  time  arrives. 
This  must  be  done  on  a  plan  by  which  there  is  practically  no 
danger  of  failure  in  the  sending  of  such  a  notice,  for  if  the 
dentist  assumes  the  responsibility  of  notifying  the  patient,  and 
then  fails  to  do  so,  the  patient  will  have  good  cause  to  blame 
him.  Many  patients  will  welcome  such  a  plan  and  will  be  so 
impressed  with  the  whole  scheme  of  treatment  and  the  interest 
manifested  by  the  dentist,  that  they  will  undertake  their  part 
more  earnestly. 

On  the  occasion  of  each  subsequent  examination,  the  dentist 
should  refer  to  his  previous  examination  record,  and  should 
make  a  careful  inspection  of  all  positions  from  which  deposits 
were  removed  to  note  how  successful  the  patient  has  been  in  the 
cleaning.  Whenever  a  deposit  is  found,  it  should  be  pointed 
out  to  the  patient,  and  directions  given  for  the  better  care 
required  in  the  future.  At  the  same  time  a  record  should  be 
made  of  whatever  deposits  are  found  and  the  patient  should 
know  that  this  is  done.     Then  the  deposit  should  be  removed. 

Such  a  plan  of  recording  places  of  deposit,  and  checking  up 
the  care  by  the  patient  at  each  sitting,  together  with  the  educa- 
tion of  the  patient  as  to  the  nature  of  the  deposit  and  training 
in  the  cleaning  necessary  to  its  prevention,  all  carried  out  with 
an  enthusiasm  and  earnestness  on  the  part  of  the  dentist,  will 
not  fail  to  procure  the  earnest  cooperation  of  most  patients. 
Tliis  is  especially  true  if  the  patient's  attention  is  called  to  the 
ahnost  certain  eventual  loss  of  those  teeth  which  are  neglected. 
For  such  persons  this  plan  of  treatment  will  not  fail.  It  is 
dependable. 

Patients  who  can  not  be  induced  to  take  at  least  fair  care 
of  their  mouths,  may  as  well  be  advised  that  their  cases  are 
hopeless. 

Fixation  of  teeth  that  have  been  loosened  as  a  eesult  of 
deposits  of  salivary  calculus. 

It  not  infrequently  happens  that  teeth  which  are  loosened 
as  a  result  of  the  destruction  of  a  part  of  their  investing 
tissue  by  the  deposit  of  salivary  calculus  will  with  proper 
treatment  again  become  tight.  If,  following  the  removal  of  the 
deposit,  the  teeth  are  kept  clean,  the  remaining  tissue  of  the 
peridental  membrane  may  shrink  down  and  hold  the  teeth  firm 


Fig. 


Fig.  177.  Bottle  eontainiug  100  sodium  chloride  tablets  and  an  ordinary 
(Iriiikiug  class  (illustration  actual  size)  containiuff  eight  ounces  of  water.  Two  salt 
tablets  of  IQ^  grains  each  should  be  adde<l  to  eigiit  ounces  of  water  to  make  a 
physiological  salt  solution.  It  is  reconinKMide.l  that  patients  prepare  the  «nlt  ^olnti.ni 
in  this  way  for  home  use. 


Tig.  its. 


Fig    178      Radiograph  of  a  ease  in  which  an  appliance  is  holding  the  four  lower 
incisors  together,  all  hough  the  centrals  have  lost  almost  all  of  their  bony  attachment. 


INFLAMMATIONS    DUE    TO    SALIVARY    CALCULUS,  113 

against  direct  jjressure  in  mastication,  if  the  occlusion  is 
squarely  down  upon  the  teeth.  If,  however,  the  teeth  should 
be  inclined,  or  the  wear  of  the  surface  should  be  more  on  the 
buccal  than  on  the  lingual,  or  the  reverse,  the  force  exerted  is 
inclined  to  drive  the  tooth  to  the  one  side  or  to  the  other. 
In  cases  in  which  the  destruction  of  the  membrane  has  not  been 
too  great,  the  loose  teeth  may  be  fixed  in  position  by  an  artificial 
appliance  which  will  hold  them  against  lateral  strain,  and  thus 
give  the  remaining  investing  tissues  opportunity  to  regain  their 
normal  tone.  Many  of  these  shaky  teeth  will,  as  a  result  of  the 
reduction  of  the  swelling  around  the  apex  of  the  root,  the  thin- 
ning down  of  the  membrane  and  the  apparent  strengthening  of 
the  fibers,  do  service  for  many  years,  if  they  are  kept  clean. 
After  several  months  the  fixture  may  be  removed.  After  the 
teeth  have  become  firm,  they  will  usually  do  better  without  the 
appliance,  because  they  can  much  more  readily  be  cleaned. 

Whatever  form  of  appliance  is  used,  it  should  be  so  con- 
structed that  it  will  be  entirely  free  from  the  soft  tissues,  being 
attached  to  the  crowns  as  far  away  from  the  gingivae  as  possible. 
It  should  be  so  made  for  the  double  purpose  of  avoiding  irrita- 
tion to  the  gingivsB,  and  to  permit  the  most  thorough  cleaning 
of  the  portions  of  the  teeth  near  the  gingivae.  Fixing  such  ca,ses 
with  appliances  that  reach  to  the  gums  makes  proper  cleaning 
impossible  and  invites  deposits  of  calculus  and  food  debris. 
The  danger  of  such  foci  in  the  mouth  to  the  general  health  has 
been  pointed  out,  and  it  is  unquestionably  better  to  extract  the 
loose  teeth  than  to  retain  them  under  such  conditions. 

There  are  many  ways  in  which  such  teeth  can  be  fixed  in 
position.  Comparatively  narrow  bands  may  be  fitted  to  the 
crowns  without  impinging  on  the  margins  of  the  gingiva^.  These 
bands  should  include  the  loose  tooth  or  teeth  and  at  least  one 
firm  tooth  on  either  side.  In  cases  in  which  such  an  appliance 
is  to  be  placed  on  the  lower  incisors,  the  bands  may  be  made 
tolerably  heavy  and  well  reinforced  with  solder,  so  that  the 
labial  portion  for  each  tooth  may  be  cut  away  after  the  appli- 
ance is  cemented  to  place.  This  will  then  show  of  the  gold  only 
what  will  appear  to  be  a  row  of  proximal  gold  fillings.  Lingual 
plates  may  be  swaged  or  cast,  and  fitted  with  small  platinum 
pins  which  extend  part  way  or  entirely  through  the  crowns  of 
the  teeth,  being  placed  far  enough  incisally  to  avoid  the  ]iulp 
chambers. 

Other  plans  will  bo  quite  as  satisfactory.  It  is  not  within 
the  scope  of  this  1)ook  to  describe  these  in  detail;   only  to  call 

13 


114  SPECIAL   DENTAL   PATHOLOGY. 

attention  to  the  advantage  of  such  appliances  in  some  cases  in 
which  the  teeth  are  loose,  but  have  a  considerable  portion  of 
their  investing  membranes  remaining.  WHien  teeth  have  become 
so  loose,  on  account  of  the  extensive  destruction  of  the  invest- 
ing tissues,  that  they  will  not  be  likely  to  again  become  tight, 
they  had  better  be  extracted  at  once,  and  replaced  by  a  bridge 
or  some  other  appliance. 

The  rule  should  be  that  a  tooth  which  can  be  used  without 
too  much  discomfort,  should  not  be  held  in  place  with  an  appli- 
ance. The  tooth  will  become  fixed  in  its  position,  if  not  driven 
out  by  some  other  forces  mentioned  above,  much  better  if  left 
without  a  band.  One  effect  of  the  motion  of  the  tooth  in  the 
chewing  of  food  is  a  stimulation  to  the  remaining  portion  of  the 
membrane  about  the  root,  which  serves  to  strengthen  the  fibers 
and  the  portion  of  alveolar  process  about  it,  so  that  these  tissues 
become  strong  enough  to  support  it.  This  is  to  be  sought 
usually,  instead  of  supporting  the  tooth  by  bands.  Bands  give 
the  patient  comfort,  it  is  true,  for  the  time  being,  but  generally 
the  fancied  security  contributes  to  negligence  in  the  cleaning 
process  and  the  teeth  will  be  lost  sooner  than  if  the  bands  had 
not  been  used.     (See  Figure  178.) 

Some  of  the  best  recoveries  of  teeth  which  have  been  loose, 
under  my  own  observation,  have  resulted  from  redoubling  the 
effort  of  cleanliness  and  depending  upon  patients  to  avoid  hurt- 
ing the  teeth  until  the  natural  reparation  forces  have  tightened 
them.  I  have  seen  teeth  which  were  very  loose,  notwithstanding 
the  fact  that  there  was  an  abundant  amount  of  peridental 
membrane  about  the  roots  to  hold  them  firmly  in  position,  if  the 
inflammation  could  be  controlled.  It  is  only  those  which  are 
liable  to  be  forced  out  of  position  by  the  pressure  of  mastication 
that  should  have  bands  for  fixation.  When  the  occlusion  comes 
squarely  upon  the  teeth,  they  will  do  better  without  bands. 

An  interesting  case  of  a  very  loose  tooth  which  became  tight 
as  a  result  of  exceptionally  careful  cleaning  is  reported  under 
training  in  cleaning  the  mouth  in  the  discussion  of  Mouth 
Hygiene. 


GINGIVITIS   DUE   TO    SERUMAL   CALCULUS.  115 


GINGIVITIS   DUE   TO  DEPOSITS  OF 
SERUMAL  CALCULUS 

ILLUSTRATIONS:    FIGURES  179-185. 

This  distinct  type  of  gingivitis  is  caused  by  the  deposit  of 
serumal  calculus  on  the  enamel  in  the  subgingival  space.  The 
term  serumal  calculus  is  applied  to  the  deposit  occurring  on  the 
enamel  under  the  free  margin  of  the  gingivae,  or  on  the  cementum 
after  the  peridental  membrane  is  detached.  The  term  was  first 
suggested  in  a  paper*  which  I  read  before  the  Illinois  State 
Dental  Society  in  1882.  The  late  Dr.  L.  C.  Ingersoll,  of  Iowa, 
had  used  the  term  sanguinary  calculus,  and  contended  that  it 
was  a  deposit  from  liquor  sanguinis  that  exuded  from  the  tissues 
in  a  state  of  irritation  or  inflammation.  I  believed  then,  as  I  do 
now,  that  the  first  deposit  of  this  calculus  is  brought  to  the  sub- 
gingival space  by  the  normal  subgingival  fluid,  or  possibly 
during  some  excitation  of  the  normal  flow.  In  the  absence  of  a 
definite  gland  this  fluid  should  be  termed  a  serum  —  an  exuda- 
tion, rather  than  a  secretion. 

Causes  of  deposit  and  conditions  of  occurrence. 

The  underlying  causes  of  the  deposit  of  serumal  calculus 
are  not  different  from  the  causes  of  deposits  of  salivaiy  calcu- 
lus. As  previously  mentioned,  the  subgingival  spaces  are  kept 
constantly  moist  by  the  exudation  of  a.  serum  from  that  portion 
of  the  free  gingivae  which  normally  lies  in  contact  with  the 
enamel.  Under  normal  physical  conditions  this  serum  contains 
no  calco-globulin,  but  under  those  conditions  already  descri1:)ed 
under  which  calco-globulin  is  present  in  the  fluids  secreted  from 
the  salivary  glands,  we  would  also  expect  to  find  a  calco-globulin 
present  in  the  other  juices  and  fluids  of  the  body,  and  excreted 
with  them.  The  serum  which  bathes  the  subgingival  spaces 
should  contain  its  proportion  of  calco-globulin,  and  depending 
on  the  quantity,  it  might  be  expected  that  this  would  find  n  place 
of  deposit  on  the  enamel  of  the  subgingival  space.  Doubtless 
much  of  it  passes  out  from  the  subgingival  space  and  becomes 

*  Phagedena  Pericementi,  by  G.  V.   Black.     Proceedings  Illinois   State   Dental 
Society,  1882,  p.  93.    See  p.  98,  second  paragraph. 


116  SPECIAL   DENTAL    PATHOLOGY. 

mixed  in  tlie  saliva,  while  that  which  remains  is  not  disturbed 
by  the  cleansing  of  mastication,  nor  by  the  artificial  cleaning 
methods  ordinarily  employed. 

Therefore,  it  seems  logical  to  state  that  there  may  occur  a 
more  or  less  general  deposit  of  serumal  calculus  on  the  enamel 
of  the  subgingival  spaces,  as  a  result  of  the  excretion  of  calco- 
globulin  with  the  serum  which  is  normally  discharged  into  these 
spaces.  We  might  also  find  an  excessive  deposit  of  serumal 
calculus  on  the  enamel  of  certain  subgingival  spaces  as  a  result 
of  irritation  or  inflammation  of  the  overlying  soft  tissue,  because 
under  such  conditions  an  excessive  amount  of  serum,  which 
might  be  charged  with  calco-globulin,  would  be  i)oured  out  into 
these  spaces.  Or  we  might  find  a  deposit  of  serumal  calculus 
in  a  single  subgingival  space  and  nowhere  else,  in  a  case  in 
which  the  tissue  overlying  the  particular  space  was  irritated 
or  inflamed,  causing  an  excessive  outpouring  of  serum.  The 
amount  of  calco-globulin  in  the  serum  might  be  so  slight  that  in 
all  spaces  not  subjected  to  irritation,  there  would  be  insufficient 
quantity  of  calco-globulin  brought  to  the  spaces  over  a  long 
]ieriod  of  time  to  make  an  appreciable  deposit,  while  the 
increased  discharge  from  the  irritated  tissue  might  bring  a 
sufficient  quantity  to  give  a  definite  deposit  in  a  comparatively 
short  time. 

It  should  also  be  recognized  that  some  individuals  appar- 
ently practically  never  have  an  excess  of  calco-globulin  dis- 
charged with  the  saliva  or  other  secretions,  and  we  should  not 
expect  to  find  deposits  of  serumal  calculus  in  the  mouths  of  such 
persons,  even  in  those  spaces  where  the  inflammation  of  the 
overlying  tissue  is  marked.  However,  since  most  of  the  inflam- 
mations of  the  gingivnp  are  permitted  to  go  on  year  after  year 
without  attention,  there  will  usually  be  a  deposit  in  such  places, 
because  it  is  probable  that  few  persons  are  continuously  free 
from  paroxysms  of  excess  of  calco-globulin. 

We  should  generally  expect  to  find  deposits  of  salivary 
calculus  in  mouths  in  which  deposits  of  serumal  calculus  are 
present,  as  the  same  condition  would  result  in  the  outpouring 
of  calco-globulin  in  the  saliva  and  subgingival  fluids  simul- 
taneously. The  deposits  of  salivary  calculus  need  not  neces- 
sarily be  present,  however,  because  the  local  conditions  in  those 
positions  in  which  salivary  calculus  would  generally  be  found, 
may  be  unfavorable  for  an  accumulation  of  the  deposit;  or  any 
accumulations  which  have  occurred,  may  have  been  removed  by 


Fic.    179. 


Fig.  179.  I'liutoinicrograi.h  i'n.in  :i  Mctioii  uf  u  .tumiIi  »['  very  lihick  scriiiiial 
calculus.  (Sfo  (losciiptiou  of  proooss  ul'  yriiidiiig,  in  Aiipciulix  ut'  lliis  book.)  Tlie 
outer  surface  is  the  lower  border  of  the  picture,  upon  wliich  uccretidu  was  in  projjress. 
It  gives  a  slight  showing  of  masses  formod  by  splicrnli's  of  frlolinliii.  The  irregular 
veining  shows  lines  of  accretion. 


*13 


Fig.   KS(I. 


Fjc;.   ISl. 


l'i(i.  182. 


Pigs.    ISO,    181,   182.      I)i;i\vinj-s   to    ilhistrato  the   ]iositi(>iis    in    uhidi    deposits   of 

scnuiial    calfiilus    occur    on    llic    surfaco    ot    the  ciiiuuel    in    the    siiliuingival    space. 

Deposits    in   this   position    are   usually   flat    scales,  wiiile   those   on    tiie    roots  are    more 
lieiierally   uoiiular. 

I'"i(..  isii  shows  a  (lejiosit  of  serunia!  ealciihis  iiiider  the  free  <;iiigi\a  on  tin'  laiiial 
surface  of  the  enamel  of  a  lower  incisor  tooth. 

Fig.  181  shows  a  similar  deposit  on  tiie  linouai  surface  of  an  upper  incisor. 
Supi)uration  of  the  peridental  membrane,  resulting  from  deposits  in  this  position, 
causes  the  teeth  to  move  labially.  and  siudi  cases  are  generally  ho])eless,  after  much 
pr<igress  has  been  made.     (See  Figures  2G0,  261.) 

Fig.  1S2  shows  an  upper  molar  with  deposits  of  serunial  calciiius  on  tiu'  enamel  of 
liiitli   the  liiH-cal  am!   lingual  surfaces. 


GINGIVITIS    DUE    TO    SEEUMAL    CALCULUS.  117 

the  vigorous  use  of  the  teeth  in  mastication,  or  by  artificial 
cleaning,  neither  of  which  would  disturb  the  serumal  deposit. 

It  should  generally  be  the  case,  however,  that  no  deposits 
of  salivary  calculus  will  be  found  in  those  mouths  in  which  well- 
marked  inflammations  of  the  gingivae  have  existed  for  a  con- 
siderable time,  say  a  year  or  more,  without  any  deposit  of 
serumal  calculus  having  occurred  in  such  positions.  In  such 
cases  there  would  have  been  a  continuous  outpouring  of  an 
excessive  quantity  of  serum  from  the  inflamed  areas,  and  if  there 
had  been  insufficient  calco-globulin  to  form  deposits  in  such  posi- 
tions, it  would  be  expected  that  no  calco-globulin  had  been 
secreted  with  the  saliva  during  the  period  of  inflammation. 

COMPAEISON   OF   SERUMAL   WITH    SALIVARY   CALCULUS. 

Serumal  calculus  is  more  compact  and  is  harder  than  sali- 
vary calculus.  Its  color  is  a  dark  brown  or  black,  often  intensely 
black,  and  if  broken,  it  is  lustrous  when  washed  and  dried. 
No  analysis  of  this  calculus  seems  to  have  been  published.  This 
is  probably  because  of  the  difficulty  of  obtaining  it  in  sufficiently 
large  quantities.  Formerly,  I  had  supposed  that  serumal  calcu- 
lus was  a  different  order  of  deposit  from  salivary  calculus,  or 
that  it  was  a  crystalloid*  form  instead  of  a  granular  form  such 
as  we  find  in  salivary  calculus.  Since  I  have  been  able  to  grind 
fine  sections  of  the  two  varieties  for  microscopic  examination, 
I  have  found  little  difference  in  their  structure,  except  that  the 
serumal  deposit  is  more  dense.     (See  Figure  179.) 

Gingivitis  due  to  the  deposit. 

The  first  effect  of  a  deposit  of  serumal  calculus  in  the  sub- 
gingival space  is  to  cause  an  irritation  of  the  gingiva^.  If  my 
supposition  expressed  above  is  correct,  this  irritation  tends  to 
an  increase  in  the  deposit  by  causing  more  serum  to  be  poured 
into  the  space,  and  this  in  turn  increases  the  irritation.  The 
deposit  adheres  very  closely  to  the  enamel  of  the  subgingival 
space.  (See  Figures  180  to  185.)  The  overlying  free  gingivic 
have  a  darker  cast  than  normal,  caused  by  the  dark  color  of  the 
calculus  showing  through  the  tissues  which  cover  the  deposit. 

*  The  term  crystalloid  indicates  a  form  which  is  similar  to  a  crystal,  but  is  not  a 
true  crystal  form  in  the  chemical  sense.  The  crystalloid  form,  as  found  in  the  bodies 
of  animals,  always  has  a  basis  of  colloid  material.  The  calco-spherites  are  a  similar 
form  of  deposit.  Indeed,  there  are  no  crystals  in  organic  matter  or  material  used  by 
life  force  in  constructive  meta.bolism.  Many  compounds  crystallize  out  from  solutions 
when  the  life  force  lets  them  go.  Even  tlie  enamel  rods,  that  contain  the  least  organic 
matter  of  any  organic  material,  are  not  crystallized.  Enamel  does  not  decompose 
light,  as  its  principal  chemic^il  compound  will  do  when  dissolved  and  crystallized  aa 
an  inorganic  body. 

13b 


118  SPECIAL    DENTAL    PATHOLOGY. 

In  positions  where  the  gingivae  are  thin,  the  deposit  underneath 
will  show  through  as  a  bluish  spot  in  the  soft  tissue.  If  the 
deposit  is  removed  the  spot  disappears. 

Compression  of  deposits  by  the  gingiva.  I  have  thought 
the  greater  density  of  sei-umal  as  compared  with  salivary  cal- 
culus might  be  due  to  compression  from  the  gingivae  in  forming 
the  mass  when  soft.  The  form  of  the  usual  scale  and  its  smooth, 
rounded  surface  would  indicate  this.  It  is  probable  that  during 
any  one  of  the  inflammatory  periods  the  grasp  of  the  soft  tissue 
upon  the  tooth  or  upon  a  previous  deposit  of  calculus  is  relaxed 
by  the  swelling  of  the  tissue,  giving  room  for  the  deposit.  Then 
the  soft  mass  seems  to  relieve  this  irritation,  and  the  recovery 
of  the  tissue  causes  it  to  draw  tightly  over  the  soft  deposit  and 
smooth  it  down  into  the  form  of  the  scale  which  occurs  in  this 
position.    In  this  way  the  mass  grows. 

Variations  in  location  of  deposits. 

In  many  cases  the  deposit  of  serumal  calculus  is  confined  to 
small  points  on  tlie  buccal,  labial  or  lingual  sides  of  the  teeth, 
rather  than  the  proximal  sides.  We  will,  however,  sometimes 
find  rings  of  this  calculus  which  completely  encircle  the  teeth. 
(See  Figures  183,  184  and  185.) 

My  personal  observation  has  been  that,  while  none  of  the 
teeth  are  exempt  from  deposits  of  serumal  calculus,  it  occurs 
most  frequently  in  the  front  part  of  the  mouth,  especially  on  the 
incisors  and  cuspids,  which  give  the  greater  number  of  cases, 
and  the  bicuspids  a  less  number,  and  the  molars  the  least.  The 
third  molars  are  involved  more  frequently  than  either  the  first 
or  second  molars. 

It  is  very  liable  to  involve  and  destroy  the  membranes  of 
one  or  two  or  several  teeth  and  leave  others  uninjured.  This 
occurs  because  of  the  fact  that  a  suppurating  pocket  once  estab- 
lished will  go  on  and  on,  often  very  slowly,  but  continuously, 
until  the  tooth  is  lost.  As  has  been  mentioned,  there  may  be  a 
general  deposit  in  many  or  all  subgingival  spaces,  or  in  any 
particular  position  in  which  an  irritation  of  the  gingiva  has 
occurred. 

Suppuration  involving  peridental  membrane. 

The  greatest  danger  from  the  inflammations  caused  by  these 
deposits  is  to  the  attachment  of  the  peridental  membrane. 

As  the  inflammation  increases,  suppuration  usually  occurs. 
The  point  of  the  beginning  of  suppuration  is  at  the  gingival 


GINGIVITIS    DUE    TO    SERUMAL    CALCULUS.  119 

line,  and  the  attachment  of  the  peridental  membrane  is  first 
destroyed.  As  this  progresses,  the  gingivae  may  shrink  away 
and  become  shorter,  exposing  the  first  deposit.  Then  another 
line  of  deposit,  if  it  has  partly  encircled  the  tooth,  is  apt  to 
occur  in  the  space  gained.  By  this  time,  the  suppuration  of  the 
adjacent  peridental  membrane  may  form  a  pocket  along  the  side 
of  the  root  of  the  tooth  and  a  suppurative  pericementitis  has 
been  established. 

I  remember  one  case  in  practice  in  which  I  found  a  little 
pus  pocket  confined  to  the  disto-labial  angle  of  an  upper  lateral 
incisor,  caused  by  a  small  nodule  of  serumal  calculus.  There 
were  also  several  small  nodules  elsewhere  in  the  mouth,  but  this 
was  the  only  point  of  suppuration.  This  one  point  healed  read- 
ily by  a  little  careful  handling,  but  afterward  there  was  a  deep 
scallop  in  the  crest  of  the  free  gingiva  at  that  point,  because  of 
the  detachment  of  the  peridental  membrane  from  the  tooth  and 
the  injury  of  some  portions  of  other  supporting  tissue  by  suppu- 
ration. This  patient  was  frequently  in  my  chair,  for  ten  years 
afterward,  but  there  was  no  other  deposit  of  serumal  calculus. 
Neither  was  there  any  betterment  of  the  deformity  of  the  gin- 
giva by  reattachment  over  the  space  of  the  destruction  of  the 
fibers  of  the  membrane. 


120  SPECIAL    DENTAL,   PATHOLOGY. 


TREATMENT  OF  GINGIVITIS  DUE  TO  DEPOSITS 
OF  SERUMAL  CALCULUS. 

ILLUSTRATIONS:    FIOURES  18G-18S. 

The  treatment  of  inflammations  of  the  gingiwT,  caused  by 
deposits  of  serumal  calculus,  should  be  along  the  same  general 
lines  as  the  treatment  of  inflammations  caused  by  deposits  of 
salivary  calculus.  The  principal  points  of  difference  are  in  the 
instruments  used  and  technic  employed  in  removing  the  deposits, 
and  the  greater  importance  of  the  rubber  bulb  syringe  both  in 
the  care  by  the  dentist  and  in  the  after  treatment  by  the  patient. 
In  those  cases  in  which,  in  addition  to  the  deposit  of  serumal 
calculus,  there  is  apparent  an  exciting  cause  of  the  inflammation, 
other  than  the  deposit,  it  will,  of  course,  be  necessary  to  remove 
such  cause,  whatever  it  may  be.  The  dilTerent  injuries  to  the 
gingivae  and  their  treatment,  are  considered  elsewhere. 

The  treatment  should  consist:  First,  of  the  thorough 
removal  of  the  deposits,  and  the  care  of  the  tissues  by  the 
dentist  until  the  inflammation  has  subsided;  second,  the  train- 
ing of  the  patient  in  the  means  of  preventing  redeposits ;  third, 
subsequent  examinations  at  stated  intervals  to  criticize  the  care 
by  the  patient  and  to  remove  any  deposits  which  may  have 
occurred. 

Removal  of  deposits  and  care  of  tissues  by  the  dentist. 

The  removal  of  deposits  of  serumal  calculus  is  an  entirely 
different  matter  from  the  removal  of  deposits  of  salivary  cal- 
culus. Serumal  calculus  is  deposited  in  the  su])gingival  spaces, 
is  covered  by  the  free  gingivae,  and  hidden  from  view.  The 
deposits  are  usually  in  the  form  of  flattened  scales  which  cling 
very  tenaciously  to  the  surface  of  the  enamel.  It  requires  a 
very  sharp  instrument  and  considerable  force  to  dislodge  them. 
Care  should  be  exercised  to  do  the  least  possible  injury  to  the 
gingivae  in  connection  with  this  operation. 

As  mentioned  in  connection  with  the  treatment  of  gingivitis 
caused  by  deposits  of  salivary  calculus,  a  careful  record  should 
be  made  of  the  positions  in  which  deposits  are  found  when  the 
mouth  is  examined.     This  record  should  be  made  before  the 


riu.  is;]. 


Fig.  1S4. 


Fig.  ^S^,. 


Figs.   IS.'i,  ^H4.   is.').      Tliree   molar  tc<'tli   sliuwin;^-  •■riii<i;s"   of   (lo|)()sit  of  scnimal 

i-alculus  on  tlio.  (Miaiiicl    of  tlic  suhtrinjrival    sjiacc.      I'n'.iiiriit  l,v   tlifsc   "  riiifjs  "  ciicii-cli 

the  c-rowii.     S|iccimci]s  from   Ndrt  liwcstiTii   I 'iiixcrsit  v   Dental  .Miismin.      l-'i^rnrc  IM  was 
prpspntcil   l,_v    .Mr.    Il,-in,l,l    .\,    IIuoiht.  a   stihlcnt    in   the  school. 


Flu.    ISG. 


Fig.  18G.  A  set  of  scalers  for  removing  deposits  of  serunial  calculus.  These 
were  designed  especially  for  the  removal  of  deposits  from  pus  pockets  and  the 
directions  for  their  use  are  given  in  discussing  the  removal  of  deposits  in  the 
palliative  treatment  of  clironic  suppurative  periceiiieutitis.     (See  Figures  26S  to  282.) 


GINGIVITIS    DUE    TO    SEKUMAL    CALCULUS.  121 

operation,  or  while  the  removal  of  the  deposits  is  in  progress, 
and  it  should  be  verified  and  corrected,  making  additional  entries 
for  any  deposits  found  which  were  not  previously  noted.  This 
record  should  be  made  with  the  intention  of  referring  to  it  and 
comparing  the  conditions   found  on  subsequent  examinations. 

In  the  removal  of  serumal  calculus,  different  instruments 
from  those  for  removing  salivary  calculus  should  be  used. 
These  should  be  narrow,  flat  blades.  These  blades  should  have 
square  ends,  ground  with  very  sharp  edges  for  use  with  a  push 
motion,  or  should  be  armed  on  the  flat  side  with  a  short  l)lade, 
in  hoe  form,  with  a  cutting  edge,  which  may  be  used  with  a  pull- 
ing motion.  These  edges  should  be  kept  very  sharp  to  be  effec- 
tive. The  deposits  may  be  well  removed  by  either  form  of 
instrument.  Some  men  have  preferred  one  of  these  forms,  some 
the  other.  In  the  use  of  either  form,  the  greatest  difficulty  is 
to  succeed  in  removing  the  calculus  without  injuring  the  attach- 
ment of  the  peridental  membrane  at  the  gingival  line. 

In  the  actual  operation,  the  calculus  is  found  and  its  posi- 
tion clearly  mapped  out  by  the  movement  of  the  sharp  edge  of 
the  blade  over  the  enamel  of  the  subgingival  space.  One  of  the 
first  things  the  student  should  learn  is  to  detect  serumal  calculus 
by  the  sense  of  touch.  This  he  will  do  best  by  passing  any  one 
or  several  of  the  instrument  forms  over  serumal  deposits  which 
have  been  discovered,  and  noting  carefully  the  sensations  con- 
veyed to  the  fingers  by  the  motion  of  the  instrument  end  over  the 
calculus.  One  may  soon  learn  to  determine  very  accurately  the 
form  of  nodules,  or  even  of  very  thin  scales,  in  this  way. 

It  will  be  found  that  the  form  of  the  deposit  will  vary  from 
small  nodules  to  very  thin  scales,  the  moderately  thin  scales 
predominating.  Many  of  these  will  be  actually  in  contact  with 
the  attachment  of  the  soft  tissue  at  the  gingival  line.  Sup]iura- 
tion  will  have  caused  the  detachment  of  more  or  less  of  the 
adjacent  peridental  membrane  about  others.  Some  will  have 
been  deposited  a  little  apart  from  the  attachment  of  the  soft 
tissue  at  the  gingival  line. 

By  referring  to  the  accompanying  illustration  (Figure  186), 
it  will  be  noted  that  there  are  twelve  instruments  in  the  set  of 
scalers  designed  for  the  removal  of  those  deposits.  These  con- 
sist of  three  pairs  of  pull  scalers,  and  one  pair  of  push  scalers, 
one  instrument  of  sickle  form  and  one  cleoid  or  claw  form.  The 
set  also  includes  a  pair  of  peridental  membrane  ex]^lorers. 
Those  have  smoothly  rounded  ends  and  wore  especially  designed 
to  examine  the  line  of  attachment  of  the  peridental  membrane. 


122  SPECIAL   DENTAL   PATHOLOGY. 

In  the  use  of  the  pull  form  of  the  instrument  the  edge  of  the 
blade  should  be  slid  under  the  free  gingiva  onto  the  calculus, 
and  over  it  until  the  blade  is  felt  to  drop  against  the  enamel 
beyond  the  margin  of  the  deposit.  Then  pressure  and  a  sharp 
pull  should  be  made  in  the  endeavor  to  bring  the  scale  or  nodule 
away.  Care  should  be  exercised  in  the  manipulation  of  the 
instrument  not  to  pass  it  too  far  beyond  the  deposit  and  thus 
injure  the  tissue  attached  to  the  root.  On  the  other  hand,  if  the 
edge  of  the  instrument  is  not  passed  over  the  margin  of  the 
deposit,  the  instrument  may  slip  over  it  and  bring  nothing  away. 
It  requires  considerable  practice  in  this  instrumentation  to  do  it 
deftly.  All  of  the  sensations  of  sliding  the  instrument  to  contact 
with  the  deposit,  of  being  lifted  onto  it,  of  dropping  over  its 
edge  and  coming  in  contact  with  the  attaclmient  of  the  soft  tissue 
at  the  gingival  line  should  be  carefully  studied.  The  whole  mat- 
ter becomes  easy  of  accomplishment  as  one  acquires  dexterity. 

The  motions  of  the  push  scalers  are  the  reverse  of  those  of 
the  pull  scalers.  The  edge  of  the  blade  is  lodged  against  the 
margin  of  the  scale,  and  a  push  made  to  dislodge  the  deposit. 
In  using  these  instruments,  there  should  be  a  secure  finger  rest, 
so  that  the  danger  of  the  instrument  plunging  ahead  into  the 
soft  tissues  will  be  avoided. 

One  of  the  difficulties  occurs  when  a  thin  scale  breaks  up, 
instead  of  coming  away.  Then  individual  broken  parts  must  be 
searched  out  and  removed,  until  nothing  more  can  be  found. 

The  operator  should  usually  see  the  patient  again  within  a 
few  days,  and  examine  very  carefully  for  particles  which  were 
overlooked  at  the  first  sitting.  These  may  be  shown  by  points 
of  redness  of  the  gingivae,  or  may  have  to  be  searched  out  with 
the  explorer.  In  a  large  proportion  of  cases  the  explorer  may 
be  introduced,  and  in  cases  of  doubt,  the  free  gingivae  may  be 
lifted  a  little  apart  from  the  tooth,  so  that  one  can  see  into  the 
subgingival  space  for  the  detection  of  very  thin  scales.  In  doing 
this  great  care  should  be  exercised  not  to  injure  the  gingivae  and 
cause  them  to  stand  off  from  the  teeth.  In  cases  in  which  a 
number  of  teeth  have  deposits,  the  operation  is  apt  to  become 
very  tiresome.  The  treatment  should  not  be  done  hurriedly,  but 
should  be  adjourned  to  another  sitting  whenever  one  becomes 
fidgety  over  the  search  for  small  particles.  All  through  this 
operation  the  syringe  and  warm  water  should  be  at  hand  for 
washing  the  subgingival  spaces  for  the  removal  of  broken  parti- 
cles of  deposit  and  clearing  away  blood  which  may  impede  the 
operation. 


GINGIVITIS    DUE    TO    SERUM AL    CALCULUS.  123 

Caee  of  the  tissue  by  the  dentist.  The  after  treatment  of 
the  gingivae,  following  the  removal  of  serumal  calculus,  is  simple. 
They  should  have  a  very  thorough  washing  from  the  syringe 
loaded  with  physiological  salt  solution,  using  it  plentifully,  and 
in  such  manner  as  to  stretch  the  free  gingivae  open  and  wash  the 
subgingival  spaces  clean.  This  should  be  carefully  explained 
to  the  patient,  and,  during  the  washing,  the  patient  should  be 
asked  to  note  particularly  the  sensation  of  the  stretching  open 
of  the  subgingival  spaces  by  the  stream  of  water,  so  that  he  or 
she  may  know  when  they  have  this  sensation  in  their  own  efforts 
at  subgingival  cleaning.  No  other  treatment  is  necessary.  No 
medication  is  indicated.  In  the  cases  now  under  consideration, 
in  which  the  inflammation  is  confined  to  the  gingivae,  and  there 
has  been  little  or  no  detachment  of  the  peridental  membrane,  the 
tissues  will  return  to  their  normal  condition  within  a  few  days. 

Care  by  the  patient. 

The  most  important  training  which  the  patient  should 
receive  for  the  after  treatment  of  this  condition,  is  in  the 
use  of  the  rubber  bulb  syringe.  (See  Figures  187  and  188.)  If 
redeposits  are  to  be  prevented,  this  must  be  accomplished  by 
cleansing  the  subgingival  spaces  so  thoroughly  and  so  frequently 
that  all  of  the  calco-globulin  which  is  brought  to  the  spaces  will 
be  removed  before  it  becomes  hard.  Yet  this  is  probably  not 
the  most  important  function  of  the  syringe,  for  by  its  use  the 
gingivae  are  maintained  in  better  health  and  this  greater  health- 
fulness  prevents  the  disposition  to  the  deposit  of  serumal  cal- 
culus. Such  cleaning  must  be  done  without  irritation  to  the 
gingivae.  This  may  be  easily  accomplished  by  the  patient  by 
washing  these  spaces  twice  daily  with  the  rubber  bulb  syringe 
and  water.  This  plan  has  been  followed  for  several  years  by  a 
sufficient  number  of  patients  to  prove  its  efficacy. 

The  greatest  difficulty  will  be  met  with  in  the  matter  of 
impressing  each  patient  with  the  importance  of  this  twice  daily 
cleansing  with  the  syringe.  The  patient  may  use  plain  water 
or  physiological  salt  solution.  The  latter  will  be  preferred  by 
many.  As  previously  mentioned,  they  should  be  taught  to 
recognize  the  sensation  as  the  water  lifts  the  gingivae  away  from 
the  enamel  in  space  after  space  as  the  syringe  is  passed  around 
the  arch.  Many  persons  will  be  quick  to  appreciate  the  added 
comfort  of  the  mouth  after  each  washing,  and  will  promptly 
become  enthusiastic  in  the  use  of  the  syringe.  Others  will  do 
little  or  nothing  with  it.     Just  in  proportion  as  the  dentist  is 


124  SPECIAL   DENTAL   PATHOLOGY. 

able  to  impress  his  patients  with  the  serious  final  results  of  the 
inflammations  caused  by  the  serumal  deposits,  and  the  very 
important  part  which  their  own  care  must  play  in  prevention, 
will  he  succeed  in  securing  their  cooperation.  The  technic  of 
using  the  syringe  will  be  presented  under  Mouth  Hygiene. 

No  other  treatment  than  this  washing  is  necessarj^,  except 
it  be  the  massage  with  the  tooth-brush  in  the  usual  cleaning 
methods.  Certainly  nothing  is  to  be  gained  by  the  use  of  mouth 
washes,  tooth-powders,  etc.,  in  the  care  of  this  condition.  It  is 
entirely  a  question  of  the  thorough  mechanical  cleansing  of  the 
spaces. 

Subsequent  examinations. 

When  each  patient  is  dismissed,  there  should  be  an  under- 
standing regarding  the  time  when  the  next  examination  should 
be  made.  If  it  is  agreed  that  the  dentist  shall  notify  the  patient 
when  the  time  arrives,  a  memorandum  should  be  made  to  carry 
out  such  an  arrangement.  How  soon  the  patient  should  return 
will  depend  entirely  upon  conditions.  It  may  be  desirable  to 
set  a  time  within  a  month,  if  for  no  other  purpose  than  to  make 
some  inquiry  as  to  how  the  cleaning  with  the  syringe  is  progress- 
ing. For  most  patients  who  have  become  skilled  in  the  use  of 
the  syringe,  an  examination  every  six  months  will  be  often 
enough. 

The  record  of  the  previous  examination  should  be  consulted, 
and  every  place  where  a  deposit  was  found  previously,  should 
have  especially  careful  inspection.  Points  at  which  there  had 
been  some  suppuration  of  the  tissues  should  be  seen  frequently, 
on  account  of  the  greater  danger  of  a  recurrence.  Such  a 
suppuration,  unless  very  shallow,  is  likely  to  cause  a  slight 
dei^ression  of  the  gingiv.T,  with  a  corresponding  deviation  in  the 
even  curve  of  the  crest.  A  new  record  should  be  made  at  each 
examination,  so  that  the  full  history  of  each  case  will  be  filed 
for  reference.  In  time  these  case  histories  will  become  of  great 
value. 


Fig.  187. 


Pig.  187.  Riiliber  Imlli  svrinov  i\n-  jiMtii'iits  to  use.  lllustratiuii  actual  size. 
The  bulb  holds  1  Vj  <>iiii'fs.  'Hiis  is  ,i  mkmv  r(.iivciiient  form  for  patients  than  the 
one  shown  in  Figure  17(i.  Tlie  IkiIi-  in  \Uv  vud  of  the  nozzle  sliouhl  be  the  same, 
1%  mm.  About  %  of  an  inch  must  be  cut  off  the  nozzle  as  ordinarily  suijplied,  iu 
order  to  have  a  suflKcieutly  large  hole.     The  use  of  this  .syringe  is  shown  in  Figure  188. 


14 


J''IG.    1S8. 


Fig.  1S8.  The  position  ot  tlu'  ruMn  r  Inilli  syringe  in  wushinLr  the  subt;inj(ival 
spaces.  The  end  of  the  nozzle  shoiihl  touch  the  enamel  of  the  tooth  near  the  crest 
of  the  gingiva'  as  it  is  passe(|  along  the  arch,  the  angle  being  such  that  the  water 
or  solution  will  be  forced  into  the  subgingival  spaces.  This  is  the  most  effective 
means  of  preventing  dej)osits  of  serunial  calculus  in  the  subgingival  spaces. 


GINGIVITIS    DUE    TO    INJURIES.  125 


GINGIVITIS  CAUSED  BY  INJURIES 

ILLUSTRATIONS:    FIGURES  189-215. 

The  gingivae  stand  in  the  position  of  protection  to  the  deeper 
investments  of  the  teeth  and  their  attachment  in  their  bony 
alveoli.  These  attachments,  and  the  preservation  of  them,  are 
of  first  importance  to  the  functions  of  the  teeth.  It  is  our  duty 
as  dentists  to  look  as  closely  after  the  health  of  these  tissues  as 
that  of  the  hard  tooth  tissues,  and  to  conserve  and  protect  them 
from  injury  to  the  fullest  extent  possible. 

We  have  already  reviewed  the  injuries  which  occur  as  a 
result  of  deposits  upon  the  teeth  from  the  secretions  which  are 
poured  into  the  mouth  from  its  secretory  glands.  We  have 
noted  the  inflammations  caused  by  deposits  of  salivary  calculus, 
resulting  in  the  gradual  destruction  of  all  of  the  investing  tissues 
of  the  teeth  progressively  toward  the  apices  of  the  roots;  also 
the  gingivitis  caused  by  deposits  of  serumal  calculus  in  the 
subgingival  spaces.  Later  we  will  consider  the  progressive 
destruction  of  the  attachment  of  the  peridental  membrane 
resulting  from  such  a  gingivitis. 

Formerly  it  was  generally  believed  that  most  of  the  cases 
of  destructive  diseases  of  the  investing  tissues  of  the  teeth  were 
caused  by  deposits  of  calculus,  and  unquestionably  the  percen- 
tage of  cases  due  to  deposits  was  much  greater  in  former  years 
than  now,  the  gradual  reduction  being  due  to  the  better  care 
of  their  mouths  by  our  people.  A  critical  examination  of  the 
mouths  of  a  large  number  of  adults  will  establish  the  fact  that 
the  majority  of  cases  at  the  present  time  result  from  slight 
traumatisms  and  irritations  of  the  gingivae,  and  that  deposits 
of  calculus  are  the  first  cause  of  a  minority.  Most  cases  are 
later  complicated  by  deposits,  and  these  have  often  been  mis- 
taken for  the  exciting  cause.  It  frequently  requires  very 
careful  study  of  cases,  especially  those  which  have  made  con- 
siderable progress,  to  determine  the  beginning  or  first  cause. 

There  is  no  more  promising  field  for  the  study  and  practice 
of  prevention  tlian  in  the  group  of  conditions  which  are  the 
exciting  causes  of  the  inflammations  of  the  gingivae.  Most  den- 
tists seem  not  to  have  recognized  many  of  these  causes  at  all; 

♦14 


126  SPECIAL   DENTAL   PATHOLOGY. 

or  if  they  have  recognized  them,  they  have  failed  to  appreciate 
the  direct  relationship  between  the  apparently  trivial  gingivitis 
and  the  more  serious  lesion  of  the  peridental  membrane  which 
results.  It  should  be  understood  that  a  gingivitis  precedes  the 
pericementitis  in  every  case,  and  in  view  of  what  has  been  said 
relative  to  the  lack  of  power  of  reattachment  of  the  peridental 
membrane  to  the  cementum,  it  is  of  the  utmost  importance  that 
we  pay  more  attention  to  the  earlier  lesion,  the  gingivitis,  which 
can  usually  be  prevented  or  cured  by  very  simple  means. 

General  Statement  op  Causes  and  Symptoms. 

Faulty  contact  points*  constitute  the  chief  factor  in  the 
causation  of  this  form  of  disease  beginning  in  the  bicuspid  and 
molar  region,  where  the  heavy  work  of  mastication  is  done. 
Within  my  observation  more  cases  have  been  caused  by  faulty 
contacts  than  any  other  forms  of  injury. 

If,  for  any  reason,  there  is  a  slight  opening  between  two 
teeth,  food  which  is  tough  and  stringy  will  be  crowded  into  the 
interproximal  space  and  cause  pressure  upon  the  septal  tissue. 
Or,  if  the  contact  is  too  broad,  stringy  foods,  such  as  fibers  of 
beef  or  chicken,  are  likely  to  be  caught  between  the  flat  surfaces 
and  held  there,  thus  injuring  the  septal  tissue.  A  single  such 
occurrence  does  but  little  harm,  provided  the  food  is  promptly 
removed,  but  this  having  occurred  a  few  times,  is  liable  to  occur 
frequently,  or  even  at  each  meal  at  which  meats  or  other  stringy 
foods  are  eaten.  This  frequent  impaction  of  food  against  the 
septal  tissues  finally  becomes  habitual,  and  the  tissue  is  more 
and  more  injured  by  compression. 

Inflammation.  As  a  result  of  this  repeated  pressure  and 
irritation  the  tissue  is  inflamed  much  of  the  time.  In  the  earlier 
stages  there  may  be  redness  of  the  gingiva  in  the  particular 
space,  and  the  festoons  will  be  slightly  swollen.  The  impaction 
of  the  food  against  the  central  portion  of  the  septum  may  press 
the  buccal  and  lingual  portions  outward  in  their  respective 
embrasures.  The  tissue  will  show  marked  redness  at  inter^^als, 
and  lapse  into  a  sluggish  condition  of  chronicity  between  times, 

*  In  speaking  of  the  contact  made  by  the  contact  points  between  two  teeth  as 
they  stand  in  the  arch,  I  have  used  certain  abridged  plirascs.  For  instance,  the 
touching  of  the  contact  points  upon  each  of  two  teeth  is  spoken  of  as  the  contact,  or 
the  contact  'point;  as,  the  contact  between  the  first  and  second  molars,  or  between 
any  other  teeth;  or,  the  contact  point  was  rough,  or  the  contact  was  weak,  etc. 
The  expressions  seem  to  have  an  aptness  which  recommends  them,  and  I  have  there- 
fore made  no  effort  to  eliminate  them  from  my  writing. 


GINGIVITIS    DUE    TO    INJUKIES.  127 

when  many  obsei'vers  would  be  inclined  to  regard  the  appear- 
ance as  healthy. 

Suppuration.  After  a  time  suppuration  occurs  in  the 
secluded  space  between  the  teeth,  affecting  especially  the  attach- 
ment of  the  peridental  membrane  to  the  cementum.  There  has 
been  so  little  opportunity,  with  the  ordinary  methods  of  clean- 
ing, to  prevent  the  growth  of  micro-organisms  in  these  places, 
with  the  continuous  reinfection  which  they  afford,  that  a  chronic 
suppuration  is  maintained.  This  may  be  of  such  slow  progress 
as  to  require  years  to  accomplish  the  destruction  of  the  peri- 
dental membrane  to  the  point  of  loosening  of  a  tooth,  or  it  may 
proceed  more  rapidly. 

Complaint  of  pain  variable.  There  may  be  complaint  of 
pain  during  the  time  food  is  crowded  against  the  septal  tissue. 
Some  patients  will  complain  that  food  has  been  getting  between 
certain  teeth,  and  they  are  unable  to  continue  a  meal  until  the 
impacted  food  has  been  removed.  In  the  examination  of  the 
mouth  of  another  patient,  the  dentist  may  find  one,  two,  or 
several  septal  gingivae  threatened  with  serious  injury  from  lodg- 
ments of  food ;  or  possibly  the  case  will  have  already  progressed 
so  far  that  the  eventual  loss  of  the  teeth  is  inevitable ;  or  there 
may  even  be  considerable  amounts  of  food  debris  between  the 
teeth  at  the  time  of  examination,  and  yet  the  patient  will  insist 
that  no  inconvenience  has  been  felt. 

I  remember  well  a  case  in  point,  occurring  in  the  mouth  of 
a  man  of  prominence  in  his  community.  He  made  an  engage- 
ment to  see  me  regarding  extensive  abrasion  of  his  teeth.  When 
he  sat  in  my  chair  I  at  once  saw  that  the  septal  gingivag  between 
the  upper  first  and  second  molars  on  both  sides  were  practically 
destroyed,  and  those  between  many  other  teeth  were  seriously 
injured.  He  said  emphatically  that  he  had  had  no  pain  or 
inconvenience,  and  that  he  could  not  conceive  that  serious  dis- 
ease existed  in  his  mouth. 

I  made  an  engagement  with  this  man  to  take  lunch  with  me 
the  next  day,  without  disclosing  my  object,  which  was  to  see  him 
chew  food  on  the  lame  teeth.  To  my  surprise  he  ignored  the 
condition  absolutely  and  chewed  broiled  beefsteak  as  if  the  teeth 
were  well.  I  refused  to  build  up  his  worn  teeth  with  gold,  with 
the  statement  that  I  could  not  do  it  in  such  a  way  as  to  benefit 
him.  The  fact  was  I  was  unwilling  to  make  such  operations  in 
teeth  which  to  all  appearances  would  very  soon  lose  their  mem- 
branes. Within  the  next  year  the  case  had  progressed  to  the 
point  when  certain  teeth  were  loose  and  occasionally  sufficiently 


128  SPECIAL   DENTAL   PATHOLOGY. 

sore  to  cause  much  discomfort.  This  man  died  some  years 
later,  as  I  now  believe,  from  infection  originating  in  his  mouth. 
He  was  reported  as  having  died  from  a  recently  developed  rheu- 
matic condition  in  which  heart  sjnnptoms  occurred. 

In  this  class  of  cases  the  dentist  must  be  prepared  for  indif- 
ference by  patients  who  are  even  in  serious  condition ;  and  also 
to  hear  great  complaint  in  cases  found  to  be  trivial,  or  even 
in  those  of  which  one  can  find  no  sign  of  inflammation  and  no 
apparent  cause  at  a  first  examination. 

This  much  as  a  general  statement  regarding  the  condition 
of  pain.  It  is  utterly  unreliable  as  indicating  the  gravity  of  the 
condition.  Our  treatment  of  these  cases  should  be  based 
entirely  on  the  conditions  presenting,  without  regard  to  com- 
plaint or  lack  of  complaint  by  the  patient. 

Absorption  of  septal  tissue.  As  time  passes,  some  absorp- 
tion of  the  septal  tissue  will  occur,  beginning  in  the  central 
portion  bucco-lingually.  The  absorption  will  progress  gradu- 
ally until  the  septal  tissue  may  be  depressed  below  the  buccal 
and  lingual  gingivje,  forming  a  considerable  pocket  between  the 
teeth.  (See  Figures  189,  190  and  191.)  If  such  cases  do  not 
receive  attention,  the  destruction  of  the  soft  tissue  will  continue 
either  as  a  result  of  the  repeated  impaction  of  food  between 
the  teeth,  or  from  the  establisliment  of  suppuration  within  the 
inflamed  tissues.  Eventually,  the  inflammation  will  involve  the 
peridental  membrane  at  the  gingival  line,  detaching  it  from  the 
cementum,  forming  a  pocket  alongside  the  root.  Sometimes 
the  pressure  and  decomposition  of  food,  without  suppuration, 
will  destroy  the  attachment  of  the  peridental  membrane.  'When- 
ever the  peridental  membrane  is  detached  from  the  cementum  by 
suppuration,  it  is  the  beginning  of  a  case  of  chronic  suppurative 
pericementitis. 

Deposits  of  serumal  calculus.  Deposits  of  serumal  cal- 
culus may  or  may  not  be  present  in  these  cases.  Whenever 
there  is  an  inflammation  of  the  gingivae  from  any  cause,  the 
quantity  of  serum  poured  out  into  the  subgingival  space  is 
increased,  and  if  it  contains  calco-globulin,  a  deposit  may  occur. 
As  these  irritations  of  the  gingivae  are  often  of  long  duration, 
deposits  of  serumal  calculus  are  not  uncommon.  As  previously 
stated,  the  deposit  is  frequently  looked  upon  as  the  exciting 
cause  of  the  inflammation,  while  the  real  cause,  the  condition 
which  permits  the  impaction  of  food,  or  which  causes  the  irrita- 
tion, is  overlooked.  Certainly  a  considerable  number  of  cases 
present,  in  which  there  is  no  deposit. 


gingivitis  due  to  injueies.  129 

Classification  of  Conditions  Causing  Injueies  of  the 

Gingiva. 

There  are  so  many  conditions  which  may  cause  slight  inflam- 
mations of  the  gingiva^,  that  it  is  almost  out  of  the  question  to 
enumerate  all  of  them.  However,  it  seems  to  be  essential  to  a 
better  understanding  of  these  that  an  effort  be  made  to  classify 
them.  I  have,  therefore,  divided  them  into  the  following  groups, 
which  include  the  majority  of  causes  observed: 

Gingivitis  due ;  first,  to  lack  of  contact ;  second,  to  improper 
contact;  third,  to  deviations  from  the  normal  smooth  contour 
of  the  teeth;  fourth,  to  abuse  of  the  tissues  by  dentists  in 
operating;  fifth,  to  lack  of  cleanliness ;  sixth,  to  misuse  of  tooth- 
picks, rubber  bands,  floss  silk,  tooth-brushes,  to  accidental  inju- 
ries, etc.  Attention  has  frequently  been  called  to  these  injuries 
as  a  group,  but  it  is  evident  that  the  profession  does  not  fully 
appreciate  the  important  role  they  play  in  causing  peridental 
disease.  A  careful  study  of  the  following  pages  should  serve 
to  fix  these  so  definitely  in  the  mind  that  they  will  come  to  be 
looked  for  regularly  in  mouth  examinations.  In  the  plan  pre- 
sented for  recording  examinations,  it  will  be  noted  that  condi- 
tions falling  under  each  of  these  groups  may  be  specified.  I  am 
convinced  that  the  dentist  who  will  seriously  undertake  and 
follow  out  this  plan  of  examination,  with  accurate  records,  will 
soon  come  to  a  better  appreciation  of  conditions  and  will  apply 
preventive  treatment  more  effectively.  Failures  to  appreciate 
the  very  severe  inflammations  which  eventually  result  from  lack 
of  attention  to  this  matter  of  restoring  proper  contacts  in  opera- 
tive procedures,  have  eventually  led  to  the  loss  of  all  of  the 
teeth  of  many  individuals.  Certainly  a  very  considerable  per- 
centage of  the  cases  of  diseases  of  the  peridental  membrane  are 
due  to  failures  to  restore  proper  contacts.  The  several  condi- 
tions in  each  group  will  be  briefly  discussed. 

Gingivitis  due  to  lack  of  contact  of  the  teeth. 

Separations  following  extractions.  The  teeth  may  be 
slightly  separated  from  a  number  of  causes.  Many  such  cases 
follow  the  extraction  of  a  tooth.  If  a  first  molar  is  extracted, 
for  example,  the  second  molar  and  second  biscupid  may  be 
gradually  drawn  toward  each  other,  causing  slight  openings  of 
the  contacts  between  the  second  and  third  molars,  between  the 
first  and  second  bicuspids,  and  often  between  several  others 
farther  forward  in  the  arch.  Figure  193  shows  such  a  case, 
with  food  impacted  between  the  second  and  third  molars.     It  is 


130  SPECIAL    DENTAL   PATHOLOGY. 

in  those  cases  in  which  this  separation  is  slight,  so  that  stringy- 
foods  are  caught  and  held  between  the  teeth,  that  the  gingivjc 
are  in  greatest  danger.  In  some  cases  the  movement  of  the 
teeth  continues  until  there  is  sufficient  space  so  that  food  is  not 
held  between  the  teeth.  Under  such  conditions  the  gingiva?  are 
less  liable  to  injury.  Figure  192  shows  the  injury  to  the  septal 
tissue  resulting  from  an  open  contact  between  the  upper  lateral 
and  cuspid. 

Abnoemalities  of  occlusion.  There  is  a  lack  of  contact 
of  certain  teeth  in  a  number  of  cases  on  account  of  some  abnor- 
mality of  the  position  of  the  teeth.  This  may  result  in  the 
impaction  of  food  between  these  teeth.  Such  teeth  usually  have 
never  been  in  normal  contact,  and,  whatever  space  exists  is  not 
likely  to  change  materially  without  operative  interference. 

Uneven  occlusal  wear.  Uneven  wear  of  cusps  may  cause 
the  opening  of  one  or  more  contacts  which  were  formerly  tight. 
A  cusp  of  one  arch  will  come  to  close  with  too  great  force 
between  the  cusps  of  two  teeth  of  the  opposite  arch,  causing  them 
to  gradually  move  apart  a  little,  thus  exposing  the  septal  tissue 
to  injury. 

Weak  contacts.  When  the  pull  of  the  trans-septal,  or 
tooth-to-tooth  fibers,  is  insufficient  to  maintain  a  tight  contact 
against  heavy  stress  of  mastication,  an  inflammation  of  the 
septal  tissue  is  likely  to  occur.  This  tissue  may  appear  to  be 
inflamed  without  noticeable  cause.  A  test  of  the  contact  with 
the  ligature  will  show  that  the  teeth  are  in  proper  contact  and 
the  ligature  may  even  pass  through  with  a  snap,  yet  if  consid- 
erable pressure  with  a  large  instrument  is  made  distally  on  one 
tooth,  or  mesially  on  the  other,  it  will  be  observed  that  the  con- 
tact is  opened.  In  chewing,  the  stress  is  sufficient  in  such  cases 
to  force  the  teeth  apart  momentarily  and  crowd  a  few  fibers 
past  the  contact  against  the  soft  tissue.  This  may  occur  several 
times  at  each  meal,  and  even  though  the  impacted  food  is 
removed  with  reasonable  promptness,  the  inflammation  and 
absorption  of  the  septal  tissue  will  usually  become  gradually 
worse.  These  cases  are  more  likely  to  be  neglected  than  others 
because  of  the  difficulty  in  making  out  the  cause  of  the  inflam- 
mation. In  mouths  from  which  no  teeth  have  been  lost,  these 
weak  contacts  are  most  frequently  observed  between  second 
and  third  molars,  the  third  molar  moving  distally  under  the 
stress  of  mastication.  If  any  tooth  in  the  bicuspid  and  molar 
region  has  been  lost,  the  teeth  next  to  the  space  are  more  likely 


GINGIVITIS    DUE    TO    INJURIES.  131 

than  others  to  move  under  stress,  because  they  have  lost  the 
support  of  the  extracted  tooth. 

Decays  beginning  on  peoximal  surfaces.  Proximal  decays 
of  bicuspids  and  molars,  which  are  in  normal  contact,  often 
progress  unnoticed  or  uncared  for  until  the  lateral  decay  in  the 
dentin  along  the  dento-enamel  junction  has  undeinnined  the 
enamel  of  the  marginal  ridge  of  the  occlusal  surface.  Under 
the  stress  of  mastication  this  occlusal  enamel  is  broken  away. 
The  enamel  which  fonned  the  contact  point  is  then  lost  and  the 
opportunity  is  otfered  for  food  to  be  crowded  into  the  cavity  and 
wedged  between  the  teeth.  Persons  who  are  taking  reasonable 
care  of  their  teeth  will  generally  report  to  their  dentist  at  once 
when  this  occurs,  and  the  injury  to  the  gingivae  will  be  tempo- 
rary and  of  little  consequence.  It  is  in  the  neglected  cases  of 
this  type  that  serious  injury  occurs. 

Fillings  or  crowns  which  fail  to  make  contact.  In  cases 
in  which  fillings  or  crowns  fail  to  make  contact,  impactions  of 
food  and  inflammation  of  the  septal  tissue  results  in  exactly  the 
same  manner  as  occurs  in  those  cases  in  which  the  teeth  stand 
slightly  apart.  Figures  194  and  195  show  extensive  destruc- 
tions of  the  peridental  membrane,  both  of  which  apparently 
resulted  from  failures  to  restore  proper  contacts  in  filling  opera- 
tions. Sometimes  it  happens  that,  when  a  filling  is  placed  which 
fails  to  make  contact,  the  occlusion  is  such  that  the  teeth  move 
to  close  the  contact  and  at  the  same  time  one  or  more  neighbor- 
ing contacts  may  be  opened  by  the  movement.  Thus  the  real 
cause  of  many  slightly  open  contacts  will  be  found  upon  a  care- 
ful examination  of  other  teeth  in  the  neighborhood,  or  it  may 
even  be  in  the  opposite  arch.  Figures  196  and  197  are  of  a  case 
in  which  flat  proximal  fillings  had  been  pUiced  in  the  distal  of 
the  first  bicuspid  and  mesial  of  the  second  bicuspid,  without 
restoring  the  contact.  As  a  result,  the  second  bicuspid  moved 
forward,  opening  the  contact  between  it  and  the  first  molar. 
There  was  a  pocket  about  4  mm.  deep  on  the  mesial  side  of  the 
mesio-buccal  root  of  the  first  molar.  By  slow  separation,  the 
second  bicuspid  was  moved  back  into  contact  with  the  first 
molar,  and  properly  contoured  fillings  were  placed  in  the  mesio- 
occlusal  of  the  second  and  disto-occlusal  of  the  first  bicuspids, 
thus  holding  the  second  bicuspid  in  its  proper  position. 

Gingivitis  due  to  improper  contact  or  the  teeth. 

Abnormal  forms  of  the  teeth.  Contacts  which  are  more 
or   less   broad,    frequently    cause    a    gingivitis.     Between    the 


132  SPECIAL    DENTAL.   PATHOLOGY. 

molar  teeth,  such  contacts  are  not  uncommon.  Instead  of  pre- 
senting the  normal  convexity,  which  would  give  a  point  of  con- 
tact between  the  teeth,  the  proximal  surfaces  may  be  much 
flattened,  or  the  surface  of  one  tooth  may  even  present  a  slight 
concavity  which  fits  more  or  less  closely  the  convexity  of  the 
next  tooth.  As  a  ligature  is  passed  through  such  a  contact,  it 
will  drag  for  some  distance,  being  held  by  the  broad  contact, 
instead  of  snapping  through  as  it  would  in  case  of  a  normal 
contact.  Shreds  of  stringy  foods  are  occasionally  caught 
between  such  teeth  and,  as  time  passes,  this  is  likely  to  occur 
more  frequently  until  the  septal  tissue  is  seriously  injured. 
Figure  198  illustrates  a  case  in  which  the  distal  convexity  of  a 
lower  cuspid  lies  in  a  slight  concavity  in  the  mesial  surface  of 
the  first  bicuspid.  Figure  199  shows  a  similar  contact  between 
the  upper  first  and  second  molars.  Figure  200  is  of  a  broad, 
flat  contact  between  two  upper  molars. 

Malpositions  of  teeth.  Contacts  may  be  too  broad  on 
account  of  irregularities  in  positions  of  teeth.  If  a  tooth  is 
slightly  rotated,  or  out  of  line,  or  if  one  may  have  elongated, 
as  a  result  of  the  extraction  of  a  tooth  in  the  opposite  arch,  it 
may  present  a  surface,  less  convex  than  normal,  in  contact  with 
one  or  both  of  the  proximal  teeth,  resulting  in  the  inpaction  of 
food. 

Interproximal  wear.  As  a  result  of  the  slight  bucco- 
lingual  motion  of  the  teeth  in  mastication,  the  enamel  forming 
the  contact  points  gradually  wears,  and  the  trans-septal  fibers 
of  the  peridental  membrane  draw  the  teeth  a  little  closer  and 
closer  as  the  wear  progresses,  until  eventually  there  will  be  a 
facet  of  considerable  size  on  each  tooth  and  the  contact  will  be  as 
large  as  the  facet.  These  occur  oftenest  in  the  spaces  to  the 
mesial  or  distal  of  the  first  molar,  in  the  region  where  the 
heaviest  chewing  is  done.  Food  will  frequently  be  caught 
between  these  teeth,  particularly  in  the  mouths  of  middle-aged 
and  older  people,  although  in  some  cases  the  pull  of  the  trans- 
septal  fibers  is  so  strong  that  the  teeth  will  be  held  in  such  tight 
contact  that  no  impaction  will  occur.  Teeth  which  show  abra- 
sion of  their  occlusal  surfaces  are  more  likely  than  others  to 
also  show  considerable  interproximal  wear.  Figure  201  illus- 
trates a  case  in  which  there  was  extensive  wear  of  the  proximal 
surfaces  of  the  molars.  Figures  202  and  203  are  photographic 
reproductions  of  two  molars  with  large  facets  resulting  from 
interproximal  wear. 

Some  years  ago,  there  came  to  our  school  clinic  a  gentleman 


Fig.  1«9. 


Fig.  191. 


Figs.  ISO.  1!K),  !!)1.  Tlicsc  skct.-li(>s  illustrate  Ww  injury  to  the  sri)tiil  tissuo 
from  th<^  wodfjiiiy-  of   I'dud   hctwccn   the  tcclii   iiccansc  nf  faully  .■onta.-ts. 

Fig.    1S9   re]nvscnts  llic   nornial  (•(Hitniir  of  tiic  sf|ituin. 

Fi(i.    19(1   shows  thr   lirst    injury   resuUinj^-   from   sliji'lit   imi>actions   of   food    dohris. 

Fk;.   191   shows  the  almost  comiiloto  (Icstruction  of  tlie  S(>i)tum. 

Figs.  192  to  210  illustrate  similar  injuries  from  many  causes.  Fi<,nires  221)  to  2:'.  1 
also  illustrat(>  injuries  to  tlu^  septal  tissue. 


Fid.    l!)i 


Fig.   193. 


Fig.  li»-!.  I'liotoyraphic  rc|nudiU'lioii  of  a  [ilastiT  model  from  a  case  in  wliieli 
the  separation  of  tlie  upper  lateral  incisor  and  cuspid  liad  resulted  in  the  destruction 
of  most  of  the  septal  tissue  Ix-tween  these  teeth.  This  could  have  been  prevented  by 
the  building  of  a  proper  contact. 

Fig.  193.  Plaster  model  from  an  impression  of  a  case  presenting  with  a  mass 
of  food  debris  impacted  between  two  molar  teeth  which  were  slightly  separated. 
The  septal  tissue  was  so  badly  injured  that  there  was  no  hope  that  it  would  refill 
the  septal  space  even  though  a  good  contact  was  made.  The  case  should  have  received 
attention  long  before. 


GINGIVITIS    DUE    TO    INJURIES.  133 

about  fifty  years  old,  a  grinder  of  spectacle  lenses.  He  was  in 
some  rather  indefinite  trouble  with  an  upper  molar  tooth.  The 
Examiner  suspected  a  dead  pulp  because  of  the  marked  sore- 
ness of  the  tooth  and  redness  of  the  tissues  about  it.  The  stu- 
dent to  whom  the  case  was  assigned  started  to  open  the  pulp 
chamber,  but  found  sensitive  dentin.  Then  I  was  asked  to  see 
the  case.  I  found  the  tooth  —  an  upper  second  molar  —  quite 
sore  to  the  touch,  and  the  first  molar  was  also  sore.  I  quickly 
saw  that  the  contact  points  on  these  two  teeth  were  worn  flat 
so  that  they  would  readily  grasp  and  hold  food  which  might  be 
pressed  between  them.  At  this  time,  these  surfaces  stood  a  little 
apart,  though  there  seemed  to  be  nothing  between  them  except 
the  inflamed  septal  tissue. 

I  asked  those  who  were  looking  on  to  watch  what  I  did,  and 
taking  a  subgingival  explorer,  passed  its  blade  along  the  mesial 
side  of  the  mesio-buccal  root  of  the  second  molar  to  near  its 
apex  without  appearing  to  inflict  pain.  After  some  further 
demonstration  of  the  condition,  I  ordered  that  the  tooth  be 
extracted. 

The  condition  was  the  result  of  wedging  of  food  between 
the  flattened  contacts.  If  this  had  received  attention  when  it 
first  began  to  catch  food,  the  detachment  of  the  peridental  mem- 
brane could  have  been  avoided.  I  found  in  this  mouth,  four 
other  septal  spaces  in  which  the  tissues  were  showing  some 
shortening  and  other  signs  of  injury  from  a  similar  cause.  This 
man  had  no  caries.  I  ordered  cavities  cut  in  one  of  the  proxi- 
mal surfaces  in  each  of  the  four  cases  mentioned,  and  fillings 
made  with  sufficiently  prominent  contacts  to  prevent  the  diffi- 
culty in  the  future. 

Improperly  finished  fillings  and  crowns.  The  majority 
of  inflammations  of  this  group  are  caused  by  improperly  finished 
fillings  or  crowns.  A  filling  or  a  crown  with  a  flat  contact  will 
catch  and  hold  food  debris  and  cause  an  inflammation  of  the  sep- 
tal gingivaB  in  the  same  manner  as  will  a  flat  contact  of  two  teeth. 
Much  too  large  a  percentage  of  both  fillings  and  crowns  are 
imperfect  in  their  forms  of  contact.  We  are  also  seeing  many 
gold  inlays,  the  contacts  of  which  were  probably  of  good  form 
when  placed,  l)ut  v/hich  have  quickly  worn  flat,  because  tlie  cast- 
ing was  too  soft  to  maintain  its  form.  Thus  many  otherwise 
good  dentures  have  been  eventually  lost  as  a  result  of  lack  of 
care  in  these  operations  by  dentists.  After  one  has  mastered 
the  technic  of  securing  })roper  sei)aralion,  there  is  little  diffi- 
culty in  making  fillings  which  restore  l)oth  proper  contacts  and 


134  SPECIAL    DENTAL   PATHOLOGY. 

the  full  mesio-distal  width  of  the  interproximal  spaces.  Most 
dentists  know  how  to  do  these  things,  but  become  careless  about 
them,  seeming  not  to  realize  the  immense  amount  of  harm  that 
is  done  to  the  soft  tissues,  even  though  the  filling  or  the  crown 
may  otherwise  be  well  made.  A  little  more  time  and  care  in 
these  operations  will  serve  to  jirevent  many  thousands  of  cases 
of  peridental  disease. 

Gingivitis  due  to  deviations  from  the  normal  smooth  contour 
OF  tooth  surfaces. 

Sharp  edges  of  cavities.  Decays  of  proximal,  buccal  and 
labial  surfaces,  which  progress  until  some  of  the  enamel  rods 
have  fallen  away,  cause  inflammation  whenever  the  broken  edge 
of  the  enamel  is  under  the  margin  of  the  gingivae.  Decays  in 
these  positions  also  indirectly  cause  a  gingivitis  about  several 
adjacent  teeth,  by  reason  of  the  fact  that  the  areas  will  not  be 
properly  cleaned  artificially  by  the  patient,  on  account  of  the 
sensitiveness  of  the  decayed  areas.  Such  an  inflammation  is 
usually  of  little  consequence,  if  of  short  duration,  but,  if 
neglected,  suppuration  may  complicate  the  case  and  involve  the 
peridental  membrane. 

Imperfect  margins  of  fillings.  All  fillings  of  proximal 
surfaces,  or  gingival  thirds  of  buccal  and  labial  surfaces,  the 
margins  of  which  are  not  smoothly  finished  flush  with  the  sur- 
face of  the  enamel,  may  cause  similar  inflammations.  If  the 
cavity  is  overfull  the  projecting  edge  of  the  filling  will  be  a  suffi- 
cient irritant  to  keep  up  a  constant  slight  inflammation  of  the 
adjacent  gingiva.  If  the  cavity  is  not  fully  filled,  the  margin  of 
the  cavity  wall  will  cause  a  similar  irritation.  Sufficient  care 
has  not  been  generally  exercised  in  trimming  to  form  the  gingi- 
val margins  of  such  fillings. 

Crowns,  bridges  and  partial  dentures.  Similar  irritations 
are  caused  by  crowns  which  do  not  closely  fit  the  root  end  or 
which  impinge  on  the  attachment  of  the  peridental  membrane 
at  the  gingival  line.  Bandless  crowns,  which  either  project 
beyond  the  root  at  any  point,  or  which  fall  short  of  being  even 
with  the  root  end,  cause  irritation  in  the  same  manner  as  do 
fillings  which  are  too  full  or  not  full  enough.  Crowns  with 
bands  may  cause  inflammation  by  improper  fit  of  the  band  or 
by  any  portion  of  the  band  extending  so  deep  as  to  irritate  or 
cut  ofl?  the  attachment  of  the  peridental  membrane  at  the  gingi- 
val line.  The  tissues  are  thus  kept  in  a  state  of  irritation  for 
years  and  finally  a  ])Ocket  is  formed,  or  the  gingivae  recede,  or 


GINGIVITIS   DUE   TO   INJURIES.  135 

both  occur.  It  has  been  my  observation  that  a  large  num])er  of 
crown  bands  which  may  be  fairly  well  fitted  cause  inflammation 
because  the  root  end  has  not  been  properly  prepared  to  receive 
the  band.  The  root  should  be  so  prepared  that  the  band,  when 
in  place,  will  not  exceed  the  former  size  and  contour  of  the  tooth 
at  any  point. 

Any  portion  of  a  bridge  which  is  in  pressure  contact  with 
the  soft  tissues  causes  inflammation,  and  bridges  which  do  not 
actually  press  against  the  tissue,  but  are  so  constructed  as  to  be 
neither  self-cleansing  nor  easily  cleaned  artificially,  will  usually 
keep  up  an  inflammation  as  a  result  of  the  accumulation  and 
decomposition  of  food  debris.  Partial  dentures  may  cause  sim- 
ilar inflammations,  either  by  direct  pressure  of  clasps  or  of  the 
attachments  by  which  they  are  held  in  position. 

Gingivitis  due  to  abuse  of  the  tissues  by  dentists  in  operating. 

There  has  been  much  in  our  routine  dental  operations  that 
has  been  abusive  of  the  soft  tissues,  with  little  apparent  effort 
to  modify  the  injurious  effects  of  this  abuse.  The  tissues  are 
bound  down,  lacerated  and  pushed  out  of  form  for  varying 
lengths  of  time  while  making  fillings.  They  are  then  released 
and  the  patient  dismissed  without  attention,  instead  of  washing 
such  parts  with  warm  water,  while  Imeading  the  tissue  to  restore 
the  disturbed  capillary  circulation. 

Injuries  with  ligatures.  One  of  the  worst  forms  of  this 
abuse  is  in  drawing  ligatures  upon  the  crest  of  the  arch  of  the 
attachment  of  the  peridental  membrane  of  the  incisors  on  their 
proximal  surfaces  and  deeply  lacerating  these  tissues  and  leav- 
ing them  without  cleaning  to  inflame  and  to  suppurate.  Such 
treatment  is  unnecessarily  abusive  to  these  soft  tissues,  and 
frequently  results  in  inflammations  and  suppurations  of  the 
gingivaB  which  subsequently  involve  the  peridental  membrane. 
Figures  204,  205  and  206  show  the  gingival  lines  on  the  proximal 
surfaces  of  two  incisors  and  a  cuspid,  while  Figures  207  and  208 
show  the  proper  methods  of  tying  ligatures  around  an  incisor 
tooth.  Figure  287  is  from  a  radiograph  of  a  case  in  which  a 
pus  pocket  on  the  mesial  surface  of  an  upper  central  incisor 
resulted  from  an  injury  in  tying  a  ligature. 

Some  years  ago,  while  giving  a  lecture  on  the  technic  of 
placing  the  rubber  dam,  I  called  for  a  volunteer  from  the  class 
to  act  as  the  patient  in  the  demonstrations,  A  young  man 
stepped  out  from  a  front  seat.  He  took  the  chair  and  I  looked 
over  his  mouth  for  a  moment  in  some  amazement  1)ecause  of  the 


136  SPECIAL   DENTAL   PATHOLOGY. 

conditions  presented.  Without  a  word  to  this  volunteer  patient, 
I  turned  to  the  class  and  said:  "This  classmate  of  yours  has 
suffered  an  injury  to  the  peridental  membranes  of  his  incisors 
by  the  careless  use  of  ligatures  in  tying  the  rubber  dam,  from 
which  they  can  never  recover."  Then,  at  my  request,  this 
young  man  told  the  story  of  his  injury  to  the  class,  and  spoke 
particularly  of  the  pain  caused  by  the  tying  of  the  ligatures 
about  his  teeth.  I  took  a  subgingival  explorer  and  demon- 
strated to  the  class  the  depth  of  the  pockets  which  had  occurred 
as  a  result  of  that  purely  mechanical  injury.  Several  of  these 
reached  fully  two-thirds  the  length  of  the  roots  of  the  teeth. 
Infection  had  occurred  after  the  original  injury  and  the  suppu- 
ration would  continue  to  the  desti-uction  of  the  membranes  of 
the  teeth,  regardless  of  any  treatment  which  might  have  been 
instituted  at  that  time. 

Injuries  with  finishing  instruments  and  tapes.  In  finish- 
ing fillings,  the  soft  tissues  are  often  unnecessarily  injured  with 
knife  trimmers  and  finishing  files,  and  more  especially  with 
finishing  and  polishing  tapes.  The  various  polishing  disks  and 
points  used  in  the  engine  also  cause  a  share  of  injuries.  Many 
similar  injuries  are  caused  by  the  misuse  of  strips  and  polishing 
devices  used  in  the  so-called  oral  prophylaxis  treatments. 
Whenever  the  soft  tissues  are  injured  in  such  operations,  they 
should  be  thoroughly  washed  and  massaged  to  remove  all  parti- 
cles and  to  restore  the  circulation. 

Failures  to  remove  ligatures  and  pieces  of  rubber  dam. 
An  occasional  case  occurs  from  forgetting  to  remove  a  ligature. 
One  morning  a  student  found  a  patient,  for  whom  he  had  filled 
a  cavity  in  a  bicuspid  a  few  days  before,  awaiting  him  with  a 
very  sore  tooth.  Not  being  able  to  make  out  the  cause  of  the 
inflammation  be  requested  me  to  examine  the  case.  There  was 
an  inflammation  of  the  gingiva  which  continued  entirely  around 
the  tooth.  Taking  a  small  excavator  I  introduced  it  carefully 
into  the  subgingival  space,  and  began  to  maneuver  with  its  deli- 
cate point.  In  a  short  time  I  succeeded  in  catching  a  ligature 
with  which  the  rubber  dam  had  been  tied  and  removed  it.  Rings 
of  rubber  dam  are  sometimes  left  on  the  teeth  when  the  rubber 
is  pulled  away.  The  slender  strip  of  rubber  is  often  very  diffi- 
cult to  find.  A  piece  of  rubber  dam  torn  off  and  lodged  in  the 
subgingival  space  will  often  produce  suppuration,  and  if  not 
promptly  found  and  removed,  is  liable  to  start  the  formation 
of  a  pus  pocket. 

Other  abuses.    Similar  injuries  are  inflicted  in  the  prepara- 


FiQ.  194. 


Fig.  195. 


Fig.  196. 


FiQ.  197. 


Fig.  194.  Eadiog'-aph  of  a  case  in  which  the  peridental  membrane  had  been 
stripped  from  the  distal  surface  of  the  root  of  an  upper  first  molar  as  a  result  of 
food  passing  the  slightly  open  contact.  This  patient  had  complained  for  weeks  of 
the  .soreness  cf  this  tooth.  A  cavity  was  cut  in  a  large  mesio-ilisto-occlusal  amalgam 
filling  already  in  the  tooth,  and  the  distal  contour  was  built  out  to  make  contact 
with  the  second  molar.  This  stopped  the  injury  at  once,  and  the  tooth  has  been 
comfortable  since,  notwithstanding  the  fact  that  the  pocket  remains. 

Fig.  195.  Radiograph  of  a  case  similar  to  that  shown  in  Figure  194.  but  of  longer 
standing  :!n<l  showing  more  extensive  destruction  of  tin  inv<'stiMg  tissues,  so  tliat  it 
is  doubtful  if  a  contact  could  be  maintained. 

FlG.S.  19G,  197.  Photographs  of  plaster  models  of  a  case  before  and  after  con- 
tact restoration.  The  patient  presented  with  a  slight  pocket  on  the  mesial  surface 
of  the  root  of  the  first  molar  on  account  of  the  open  contact.  The  mesial  surface  of 
the  first  molar  and  distal  of  the  second  bicuspid  were  free  from  decay  and  had  not 
been  filled.  The  s('i>aration  had  occurred  as  a  result  of  flat  fillings  in  the  mesial 
of  the  second  liicuspid  and  distal  of  the  first  bicus]iid.  These  fillings  were  removed, 
and  a  Perry  separator  was  applied  on  several  occasions  to  move  the  second  bicuspid 
back  into  contact  with  th'>  first  molar,  it  being  held  there  for  a  tinu'  witli  fillings  of 
base-plate  gutta-percha.  Later,  pernununt  fillings  were  made  restoring  normal  con- 
ditions, as  shown  in  Figure  197.  It  was  necessary  to  relieve  tiie  occlusion  mi  the  distal 
slopes  of  the  cusps  of  the  second  bicuspid  as  it  was  moved. 


*16 


Fig.  198. 


Fig.  199. 


Fig.  198.  Plaster  inodi^l  nf  a  case  in  wliicli  tlioro  was  an  inflamniation  of  the 
septal  gingiva  between  the  lower  euspiil  and  first  bicuspid  on  aceount  of  an  aljiiormal 
form  of  the  bieuspid,  the  mesial  surface  being  slightly  concave. 

Fig.  199.  Illustration  of  an  abnormal  contact  between  the  upper  first  and  second 
molars. 


Fig.  200. 


Fig.  200.  Plaster  model  of  a  case  with  a  very  brf>ad  flat  contact  between  the 
upper  first  and  second  molars,  as  a  result  of  which  the  septal  ginjjiva  was  injured  by 
food  impaction.  Oftentimes  such  a  contact  is  so  ti^rht  that  no  food  will  be  forced 
by  it,  and  the  septal  tissue  will  not  be  inflamed.  Treatment  of  such  a  Ciise  should 
depend  on  the  condition  of  the  septal  tissue,  rather  tlian  upon  the  fact  that  the  con- 
tact is  flat.  In  the  case  from  wliich  this  cast  was  made  a  mesio-occiusal  cavity  was 
cut  in  the  second  molar,  and,  with  a  Perry  separator  iii  place,  a  gold  filliug  was 
inserted,  the  proximal  surface  being  built  sutliciently  convex  in  iiiiikr  a  good  contact. 
The  inflammation  promptly  subsided. 


Fig.  201. 


Fig.  202. 


Fig.  203. 


Fig.  'JOl.  Plaster  model  of  a  case  in  which  the  contacts  between  the  molar 
teeth  were  worn  flat.  As  with  the  case  shown  in  Figure  200,  such  contacts  may  be 
so  tight  that  no  food  will  be  forced  through,  and  the  inflammation  of  the  septal 
tissue  should  be  the  indication  for  treatment. 

FiG.s.  202,  203.  Photographs  illustrating  intorprdxinial  wear.  These  teeth  were 
extracted  because  of  the  destruction  of  the  peridental  membranes  by  the  crowding 
of  food  between  the  teeth  as  a  result  of  the  flattened  contact  points. 


GINGIVITIS    DUE    TO    INJURIES.  137 

tion  of  roots  for  crowns.  Pressure  absorption  of  the  septal 
tissues,  either  intentionally  or  not,  by  packing  gutta-percha  in 
proximal  cavities,  is  one  of  the  serious  common  injuries.  These 
are  only  types  of  abusive  treatment  of  the  soft  tissues  that 
do  great  damage.  There  are  many  others  equally  injurious. 
Every  injury  to  the  gingivae  is  an  opportunity  for  an  infection 
which  may  lead  to  the  formation  of  a  pus  pocket,  and  should  be 
carefully  looked  after  until  well. 

Gingivitis  due  to  lack  of  cleanliness. 

Lack  of  natural  cleaning.  The  natural  cleaning  of  the 
teeth  and  gingivjE  by  the  full  use  of  the  teeth  in  mastication  is 
of  the  utmost  importance  in  preserving  the  health  of  the  gingi- 
vae. The  scouring  of  the  surfaces  of  both  teeth  and  gingivae  by 
vigorous  mastication  prevents  lodgments  and  accumulations, 
and  this  prevents  the  inflammation  which  would  otherwise  occur. 
Occasional  cases  present  in  which,  on  account  of  a  sensitive  or 
tender  tooth,  the  patient  has  avoided  for  a  time  the  use  of  one 
side  of  the  mouth  in  chewing.  The  teeth  and  soft  tissues  of  the 
used  side  will  appear  clean  and  healthy,  while  those  of  the 
unused  side  will,  in  marked  contrast,  exhibit  teeth  more  or  less 
coated  over  with  lodgments  of  food  debris  along  the  margin  of 
the  inflamed  gingivae. 

Lack  of  artificial  cleaning.  In  many  mouths  in  which 
the  teeth  are  used  vigorously  in  mastication  there  will  be  lodg- 
ments of  food  debris  in  those  positions  not  well  scoured  by 
the  excursions  of  food,  also  in  any  other  positions,  which,  on 
account  of  abnormalities  of  position  or  form  of  the  teeth,  or 
of  the  gum  margins,  afford  opportunity  for  lodgments.  Such 
places  recpaire  to  be  cleaned  artificially,  and  whenever  this  clean- 
ing is  not  well  done,  the  presence  and  decomposition  of  the 
lodgments  may  cause  the  soft  tissues  to  become  inflamed. 

Gingivitis  due  to  errors  in  cleaning  operations,  accidents,  etc. 

Occasional  cases  are  seen  in  which  serious  injure  has  been 
done  to  the  gingivae  by  the  misuse  of  one  or  another  of  the 
various  things  used  in  cleaning  about  the  teeth.  The  dentist 
should  be  ever  on  the  lookout  for  such  inflammations,  and  he 
should  impress  his  patients  with  the  danger  of  such  practices 
and  urge  greater  care  in  the  future. 

Misuse  of  toothpicks.  There  are  two  kinds  of  injuries 
caused  by  toothpicks:  recession  of  the  septal  tissue  by  pressure, 
due  to  repeatedly  pushing  toothpicks  of  too  large  size  through 

18b 


138  SPECIAL   DENTAL   PATHOLOGY. 

the  interproximal  space ;  and  inflammations  caused  by  the  rough 
edges  and  splinters  of  poorly  made  wooden  toothpicks.  (See 
Figures  209  and  210.) 

I  know  of  one  case  of  a  man  of  about  thirty-five  years,  who 
had  formed  a  habit  of  biting  about  an  inch  otf  the  end  of  a 
wooden  toothpick  and  pushing  this  piece  through  the  various 
interproximal  spaces  with  his  tongue.  He  could  start  between 
the  lower  second  and  third  molars  and  push  the  piece  of  wood 
through  each  interproximal  space  all  the  way  around  the  arch, 
and  repeat  the  same  performance  on  the  upper  jaw,  the  entire 
manipulation  being  accomplished  by  the  tongue.  He  had  been 
doing  this  many  times  each  day  for  a  year  or  more  and  had 
caused  every  septal  tissue  to  recede,  exposing  the  proximal 
surfaces  of  all  of  the  teeth  for  some  distance  to  the  gingival  of 
the  points  of  contact.  A  suppuration  had  occurred  between  a 
second  and  third  molar,  destroying  a  considerable  portion  of 
the  attachment  of  the  peridental  membrane  from  the  distal 
surface  of  the  root  of  the  second  molar.  In  many  spaces  the 
tissue  was  so  badly  injured  that  a  full  recovery  was  out  of  the 
question.  Many  persons  cause  similar  injuries  in  one  or  sev- 
eral spaces  by  habitually  having  a  toothpick  sticking  between 
certain  teeth.  Patients  should  be  cautioned  against  inflicting 
such  injuries. 

Some  years  ago  I  found  so  much  damage  being  done  to  the 
septal  tissues  by  badly  made  wood  toothpicks  that  I  made  an 
outcry  against  their  use.  But  since  that  time  many  of  the  manu- 
facturers have  so  improved  their  methods  as  to  remove  this 
objection.  In  my  wanderings,  I  have  dropped  into  some  of  the 
factories  where  these  are  made,  looked  over  the  machinery  and 
talked  with  those  in  charge,  of  the  difficulties  from  both  their 
standpoint  and  ours.  There  are  still  so  many  badly  made  tooth- 
picks on  the  market  that  those  buying  should  be  careful  to  select 
only  those  which  have  been  well  made  and  the  whole  length  care- 
fully polished. 

Misuse  of  rubbee  bands  and  silk  floss.  There  is  danger 
to  the  septal  tissues  in  the  use  of  the  rubber  band  or  silk  floss  in 
cleaning  the  interproximal  spaces,  by  the  snapping  of  the  band 
or  floss  against  the  soft  tissue,  when  carried  past  the  point  of 
contact  too  suddenly.  A  single  such  injury  is  of  no  conse- 
quence, but  frequent  repetitions  will  soon  cause  a  little 
recession,  which  will  gradually  become  worse  with  continued 
irritations. 

Injuries  with  the  tooth-brush.     These  are  less  frequent 


GINGIVITIS    DUE    TO    INJURIES.  139 

than  others,  but  occur  often  enough  to  require  mention.  The 
gingivae  may  be  injured  by  the  use  of  too  hard  a  brush,  or  by 
improper  or  too  vigorous  brushing.  In  both  instances,  the 
injury  is  most  likely  to  be  to  the  buccal  or  lingual  portions  of 
the  septal  tissue.  In  this  the  brush  catches  the  margins  of  the 
gingivae  as  they  pass  around  the  angles  of  the  teeth  from  the 
buccal  or  lingual  into  the  interproximal  spaces,  and  cuts  the 
margin  away  in  these  positions.  This  is  done  with  the  mesio- 
distal  motion  of  the  brush.  I  have  only  occasionally  seen  a 
recession  of  the  labial  gingivae  which  seemed  to  be  due  to  the 
overuse  of  the  brush. 

Accidental  injuries  to  the  gingivae.  We  are  liable  to  find 
stray  points  of  inflammation,  as  I  have  sometimes  called  them, 
which  can  not  be  accounted  for,  except  we  regard  them  as  result- 
ing from  accidental  injuries.  Generally  such  injuries  last  for  a 
day  or  two  and  disappear  without  harm.  I  am  convinced  that 
some  of  the  stray  pus  pockets  which  occur  are  the  result  of  some 
accidental  injury  which  has  caused  a  suppuration  that  has  per- 
sisted after  the  character  of  the  injury  has  disappeared. 

I  have  often  felt  that  the  gingivae  of  the  lingual  surfaces  of 
the  upper  incisors  were  very  liable  to  be  injured  by  accidental 
thrusting  of  foreign  substances  under  them.  Their  position  is 
more  exposed  to  thrusts  of  food  than  any  other  of  the  gingivae. 
It  is  certain  that  I  have  found  disease  beginning  there  which  I 
was  unable  to  account  for  under  any  other  hypothesis  than  acci- 
dental injury.  A  few  times  persons  have  come  with  short 
length  of  fishbones  thrust  into  the  gingivae,  and  other  things  of 
like  sort.  Pieces  of  stiff  bristles  from  the  toothbrush  are  also 
occasionally  found.  These  things  have  generally  been  pointed 
out  by  the  patient  on  account  of  some  annoyance.  In  my 
observation  it  does  not  seem  probable  that  they  form  any  impor- 
tant part  in  the  production  of  disease,  yet  occasional  cases  of 
suppuration  occur. 

Frequency  of  Different  Forms  of  Gingivitis. 

As  to  the  frequency  of  the  various  causes  of  gingivitis  no 
thoroughly  conclusive  statistics  have  been  collected,  although 
definite  records  have  been  made  of  a  sufficient  number  of  mouths 
to  give  at  least  a  fair  idea.  Some  years  ago  I  instituted 
these  examinations  by  recording  the  conditions  found  in  the 
mouths  of  the  senior  students  at  Northwestern  University 
Dental  School.  More  recently  a  rather  widespread  examination 
has  been  made  under  the  direction  of  Dr.  Artliur  D.  Bhick,  and 


140  SPECIAL   DENTAL   PATHOLOGY. 

reports  have  been  made  to  him  of  the  findings  of  dentists  in 
various  parts  of  the  country  in  the  mouths  of  their  private 
patients.  The  following  quotation  is  from  a  paper  read  before 
the  National  Dental  Association  in  1913* : 

**  While  considerably  more  than  five  hundred  mouths  have 
been  examined,  there  will  be  presented  at  this  time  the  summary 
for  a  tabulation  covering  exactly  five  hundred  cases,  selected  by 
eliminating  the  cards  for  all  persons  younger  than  twenty  or 
older  than  thirty-five  years,  also  by  eliminating  cards  for  all 
persons  having  lesions  of  the  peridental  membrane.  This  sum- 
mary is,  then,  a  record  of  the  areas  of  gingivitis  found  in  the 
mouths  of  five  hundred  young  adults,  between  twenty  and  thirty- 
five  years  of  age,  the  average  being  26.3,  none  of  whom  have 
disease  of  the  peridental  membrane. 

"Of  the  five  hundred  mouths,  twenty-five  were  reported  as 
having  no  gingivitis,  viz.,  just  five  per  cent.  Of  these  twenty- 
five,  but  seventeen  had  all  contacts  in  good  form.  Each  of  the 
other  eight  had  one  or  more  open  contacts,  but  no  inflammation 
of  the  gingivae  at  the  time  of  the  examination.  In  the  mouths 
of  the  remaining  475  persons,  there  were  reported  4265  areas 
of  gingivitis,  viz.,  an  average  of  8.53  per  person  for  the  500 
examined. 

''There  were  1348  areas  due  to  deposits  of  salivary  calcu- 
lus; these  were  in  the  mouths  of  198  persons,  making  an  average 
of  7.8  per  person.  It  should  be  stated  that  reports  recorded 
deposit  on  more  than  one  surface  of  the  same  tooth  in  123 
instances,  and  the  very  large  majority  of  these  were  lower 
incisors  marked  as  having  exhibited  deposits  both  lingually  and 
labially.  The  percentage  of  the  500  patients  examined  who  had 
deposits  of  salivary  calculus  is  39.6.  The  percentage  of  all  of 
the  areas  of  gingivitis  reported  as  due  to  salivary  calculus 
is  31.6. 

''There  were  563  areas  reported  as  showing  serumal  depos- 
its, in  which  no  other  cause  of  gingivitis  was  recorded.  These 
were  in  the  mouths  of  75  persons,  an  average  of  7.5  areas  per 
person.  The  percentage  of  the  500  examined  who  had  deposits 
of  serumal  calculus  is  15.  The  percentage  of  all  of  the  areas  of 
gingivitis  reported  as  having  serumal  deposits  is  13.1. 

"There  were  33  mouths  in  which  deposits  of  both  salivary 
and  serumal  calculus  were  recorded,  making  a  total  of  140  per- 

*  Something  of  the  Etiology  and  Early  Pathology  of  Diseases  of  the  Peridental 
Membrane,  With  Suggestions  as  to  Treatment.  Arthur  D.  Black,  Dental  Cosmos, 
Vol.  LX,  191?.,  p.  1219. 


Fig.  204. 


Fig.  205. 


Fig.  20G. 


'2^'4p?s:^2:2^ 


Fig.  207. 


Fig.  208. 


Figs.  204,  205,  206.  Upper  central  incisor,  uppei'  cuspid,  aiul  lower  incisor, 
showing  curve  of  gingival  line  on  proximal  surfaces. 

Fig.  207.  Diagram  showing  the  relation  of  the  ligature  to  the  attachment  of 
the  soft  tissue  at  the  summit  of  the  arch  as  it  passes  hibio-lingually. 

Fig.  208.  Illustration  of  the  position  of  the  ligature  in  its  relation  to  tlie 
interproximal  attachnu'nt  of  the  soft  tissues  to  the  tooth.  If  this  is  firmly  drawn 
and  pushed  to  the  gingival  as  far  as  shown,  the  cutting  of  the  attachnuMit  of  the 
soft  tissues  to  the  neck  of  the  tooth  is  inevitable. 


Fig.  209. 


Fig.  210. 


Fig.  209.  Plaster  model  of  case  in  which  the  septal  tissue  between  the  secon^: 
bicuspid  and  first  molar  had  been  seriously  injured  by  the  use  of  a  wooden  tooth- 
pick. The  toothpick  had  been  repeatedly  pushed  entirely  through  the  interproximal 
space  from  buccal  to  lingual,  and  had  forced  the  soft  tissue  farther  and  farther 
away  from  the  contact.  This  patient  was  directed  to  use  a  rubber  bulb  syringe  after 
each  meal,  to  cleanse  this  and  other  spaces. 

Fig.  210.  Planter  model  of  lower  front  teeth.  The  primary  recession  on  both 
the  lingual  and  labial  was  due  to  deposits  of  salivary  calculus.  Later  the  patient 
formed  the  habit  of  pushing  a  wooden  toothpick  through  the  spaces  between  the 
teeth  and  caused  the  septal  gingiva)  to  recede. 


Fig.  211. 


Fig.  211.  Four  files  such  as  were  formerly  used  for  s('i):ir!itiiiK  tf.'tli  and  liuishiiiji 
proximal  gold  fillings.  The  cross-section  diagram  below  each  file  gives  an  idea  of  the 
space  which  was  left  between  the  teeth  when  sncli  files  were  used. 


FiQ.  212. 


Fig.  2VS. 


Fig.  214. 


Fig.  215. 


Figs.  212,  21."?,  214.  Diagrams  to  show  results  of  the  use  of  the  old  finishing 
files  illustrated  in  Figure  211. 

Fig.  212  shows  about  the  normal  contour  of  the  teeth  from  a  buccal  view. 

Fig.  213  shows  the  spaces  left  after  the  use  of  the  files. 

Fig.  214  shows  the  spaces  after  the  teeth  had  uuived  forward  until  they  were 
in  contact  near  their  gingival  lines. 

Fig.  21.1.  Reproduction  of  an  illustration  in  Dr.  Robert  Arthur's  book.  "Treat- 
ment and  Prevention  of  Decay  of  the  Teeth."  published  in  1871.  The  dark  lines  on 
the  proximal  surfaces  of  the  teeth  indicate  the  portions  which,  it  was  advised,  should 
be  cut  away,  fillings  being  place<l  from  tlie  direction  of  the  lingual  embrasure.  This 
method  was  suggested  as  a  substitute  for  the  former  plan  of  cutting  from  the  entire 
proximal    surface. 


GINGIVITIS   DUE   TO   INJURIES.  141 

sons  having  either  kind  or  both.  This  leaves  360  of  those  exam- 
ined for  whom  no  deposits  were  reported. 

"There  were  2354  areas  of  gingivitis  due  to  other  causes 
than  deposits,  subdivided  as  follows :  783  were  due  to  bad  mar- 
gins of  fillings  or  crowns,  496  to  lack  of  contact  of  proximal 
fillings  or  crowns,  305  to  improper  contact  of  proximal  fillings 
or  crowns,  263  to  malpositions  or  atypical  forms  of  proximal 
surfaces,  255  to  lack  of  contact  of  teeth  having  no  caries  of 
proximal  surfaces,  233  to  caries  of  proximal  surfaces,  and  19  to 
worn  contacts.  If  the  areas  due  to  malpositions,  etc.,  to  lack  of 
contact  of  undecayed  teeth,  to  caries,  and  to  worn  contacts,  are 
not  counted,  there  remain  1584  areas,  the  large  majority  of 
which  are  due  to  imperfect  dental  operations.  These  are  more 
than  37  per  cent  of  all  areas  of  gingivitis  reported.  The  per- 
centage of  all  areas  of  gingivitis  reported  as  due  to  trauma  is 
55.1.  For  all  persons  included  in  the  tabulations  there  is  an 
average  of  4.7  areas  of  gingivitis  per  person  due  to  trauma." 

It  will  be  observed  that  95  per  cent  of  all  persons  included 
in  the  tabulation  had  one  or  more  areas  of  gingivitis  and  that 
the  average  number  of  areas  per  mouth  was  8.53.  This  state- 
ment alone  should  impress  the  necessity  for  greater  care  in  the 
examination  of  cases  and  the  institution  of  procedures  for  the 
prevention  or  cure  of  such  inflammations.  It  will  also  be 
noticed  that  less  than  one-third  of  the  areas  of  gingivitis  were 
caused  by  deposits  of  salivary  calculus,  and  less  than  one-sixth 
by  deposits  of  serumal  calculus,  more  than  half  of  all  areas 
being  caused  by  injuries  and  irritations.  Attention  is  especially 
called  to  the  fact  that  1584  areas  out  of  the  total  of  4265,  or 
about  37  per  cent,  were  reported  as  due  to  imperfect  dental 
operations. 

History  of  the  Attitude  of  the  Profession  Toward  Injuries 

OF  the  Gingiva. 

The  changes  in  the  attitude  of  dentists  toward  the  preserva- 
tion of  the  gingiva)  form  an  important  element  in  the  develop- 
ment of  dentistry.  From  a  subject  in  which  no  interest  was 
manifested,  it  has  become  one  of  almost  vital  interest  to  all  the 
better  class  of  men  of  the  profession. 

For  many  years  after  I  entered  practice,  almost  no  atten- 
tion was  given  to  this  subject  by  dentists  within  my  acquain- 
tance. This  was  not  very  wide,  however,  at  that  time.  But  as 
I  now  look  back  over  that  i)eriod,  I  may  say  that  my  acquain- 


142  SPECIAL   DENTAL   PATHOLOGY. 

tance  with  dentists,  and  with  what  they  were  doing  and  striving 
for,  developed  with  fair  rapidity. 

The  use  of  noncohesive  gold  and  the  filing  of  v-shaped 
SPACES.  The  profession  was  then  using  noncohesive  gold,  with 
which  it  was  practically  impossible  to  restore  the  form  of  a 
proximal  surface  of  a  tooth,  the  occlusal  surface  of  which  had 
broken  down  at  the  position  of  the  marginal  ridge.  These 
fillings  required  a  different  standard  of  cavity  preparation  from 
that  now  in  use.  For  instance,  if  a  proximal  cavity  in  a  molar 
tooth  was  so  large  that  a  part  of  the  occlusal  enamel  was  broken 
in,  forming  what  we  now  know  as  a  mesio-  or  a  disto-occlusal 
cavity,  a  file  was  first  used  with  which  a  V-shaped  opening  was 
cut  between  the  two  teeth  of  such  width  that  the  break  in  the 
occlusal  surface  was  cut  out.  In  this  case,  if  the  tooth  which  had 
been  in  contact  with  the  decayed  one  was  not  decayed,  the  cut- 
ting was  done  with  a  safe-sided  file  so  that  the  surface  of  the 
sound  tooth  would  not  be  cut.  If  it  had  also  a  considerable 
cavity,  both  teeth  were  cut  in  a  form  which  produced  a  large 
V-shaped  space  between  them.  Four  of  these  files  are  shown  in 
Figiire  211,  and  an  idea  of  the  spaces  cut  by  them  may  be  had 
from  the  diagrams,  Figures  212,  213  and  214. 

The  cavities  were  formed  in  the  flat  surfaces  produced  by 
this  process  of  filing.  They  were  filled  and  then  finished  with 
the  same  file  with  which  the  cutting  of  the  teeth  had  been  done 
before  forming  the  cavity.  The  filling  was  finished  flat  and  level 
with  the  cut  surface  of  the  tooth.  This  left  a  broad  V-shaped 
space  between  the  teeth  with  the  acute  angle  of  the  V  toward  the 
gingiva.  In  this  space  food  would  wedge  in  chewing,  but  the 
space  so  formed  was  so  broad  and  opened  so  widely  toward  the 
occlusal  that  food  generally  did  not  remain  impacted. 

In  chewing  any  such  foods  as  meats,  especially  beefsteak, 
pressure  came  directly  on  the  gum  septum,  if  there  was  any  left 
after  the  operation,  and  produced  a  great  deal  of  pain.  This 
usually  continued  until  the  gum  septum  was  destroyed.  The 
teeth  often  dropped  together,  coming  into  contact  near  the  gin- 
gival line.  Then  food  would  occasionally  be  forced  past  this 
contact  and  lodge.  For  this  there  seemed  to  be  no  remedy  in 
sight,  even  when  the  difficulty  was  correctly  diagnosed,  which 
was  done  by  but  few  men.  Such  cases  usually  brought  on  sup- 
puration. Then  inflammation  spread,  other  contacts  loosened, 
food  lodged  in  them  also,  and  the  occlusion  went  astray,  so  that 
the  soft  tissues  became  generally  involved.    Many  of  the  cases 


GINGIVITIS    DUE    TO    INJURIES.  143 

ended  in  the  extraction  of  the  teeth  and  the  substitution  of  arti- 
ficial dentures. 

In  filling  teeth  not  so  much  decayed,  the  habit  of  the  time 
was  to  cut  with  a  flat  separating  file  to  secure  sufficient  space  to 
make  the  filling,  and  then  to  finish  the  fillings  flat  with  the  same 
file  with  which  the  teeth  had  been  separated.  This  left  a  narrow 
space  with  flat  sides  which  caught  food  and  held  it  so  that  it  was 
forced  upon  the  gum  septum,  and  in  many  cases  destroyed  this 
tissue.  This  was  the  worst  form  of  cutting  for  cavity  prepara- 
tion ever  practiced;  although  it  did  not  apparently  mutilate 
the  teeth  so  much  as  the  broad  V-shaped  cuts,  it  brought  about 
greater  destruction  of  the  peridental  membrane. 

In  spite  of  these  conditions,  some  patients  seemed  to  so 
manage,  by  certain  cleaning  processes  which  each  would  devise 
for  himself,  to  keep  the  investing  tissues  in  fairly  good  health 
and  retained  their  teeth  for  many  years.  Also,  there  were  some 
dentists,  wiser  or  more  skilful  than  the  rest,  who  so  performed 
their  operations  that  these  injuries  were  obviated  in  greater  or 
less  degree.  The  means  which  they  employed  have  long  ago 
become  inapplicable,  because  they  are  supplanted  by  better 
methods. 

Discovery  of  the  cohesive  property  of  gold  foil.  The 
cohesive  property  of  gold  foil  was  discovered  and  reported*  in 
1855  by  Dr.  Robert  Arthur,  who  was  then  teaching  Operative 
Dentistry  in  the  Philadelphia  College  of  Dental  Surgery.  This 
discovery  was  destined  to  place  dentists  in  position  to  do  away 
with  the  cutting  of  the  V-shaped  spaces  between  teeth,  and  to 
build  contacts  which  would  restore  the  teeth  to  normal  form,  so 
that  they  would  protect  the  septal  gingivae.  But  the  use  of 
cohesive  gold  to  the  best  advantage  for  this  purpose  was  very 
slow  in  its  development. 

It  required  much  time  for  men  to  learn  to  use  the  welding- 
property  of  gold  successfully.  For  this  property  was  menaced 
and  destroyed,  often  permanently,  by  substances  and  forces  not 
visible  to  the  eye,  or  that  could  be  told  by  any  other  test  than 
the  trial  of  the  gold.  Some  years  later  I  made  a  careful  study 
of  the  development  and  loss  of  the  welding  property  of  gold. 
In  fact,  I  read  my  first  paperf  liefore  a  dental  society  on  this 
subject. 


*  Dental  News  Letter,  Vol.  8,  p.  131. 

f  Gold  Foil.  Paper  read  before  Illinois  State  Dental  Society,  published  in  Mis- 
souri Dental  .Tournal,  18(59,  p.  283.  This  paper  was  subsequently  revised  and  rea.i 
before  the  New  York  Odontologieal  Society  in  1874,  and  was  ])ubiished  in  the  Denial 
CnsmoR,  Vol.  17,  187.'),  p.  138. 


144  SPECIAL   DENTAL   PATHOLOGY. 

The  tendency  after  the  discovery  of  the  cohesive  property 
of  gold  was  to  continue  the  old  forms  of  cutting  the  teeth  for 
the  preparation  of  cavities.  Dr.  Arthur  published  a  small  vol- 
ume, ''A  Treatise  on  the  Use  of  Adhesive  Gold  Foil,"  in  1857. 
In  this  volume  there  is  no  hint  of  restoring  proximal  surfaces 
to  the  normal  form.  In  this  condition  of  the  mental  conceptions 
of  dentists,  there  could  be  no  improvement  in  the  protection  of 
the  septal  tissues.  Tliis  was  not  altogether  because  of  failures 
to  recognize  these  conditions,  as  will  be  seen  by  the  record  of 
the  struggles  of  many  men  to  remedy  this  evil.  Dr.  Robert 
Arthur  himself  later  wrote  a  book*  in  which  he  introduced  a 
different  form  of  cutting  proximal  surfaces  in  the  effort  to  pre- 
vent these  injuries.  An  illustration  in  this  book  is  reproduced 
by  Figure  215.  The  plan  was  to  cut  a  V-shaped  opening  looking 
to  the  lingual,  instead  of  the  occlusal,  leaving  an  angle  of  the 
enamel  on  the  buccal  or  labial  side  to  make  contact,  and  in  this 
way  protect  the  septal  tissues.  This  form  increased  the  diffi- 
culties of  cutting  the  spaces  and  the  insertion  of  the  fillings  was 
not  so  convenient.  Under  these  conditions  very  little  use  was 
made  of  the  new  forms  proposed. 

The  wooden  wedge.  Then  there  came  a  period  of  the  wild- 
est indifference  to  the  septal  tissue.  This  was  the  era  of  wedg- 
ing teeth  apart  by  driving  wooden  wedges  between  them.  Most 
men  were  learning  to  manipulate  cohesive  gold  before  the  rub- 
ber dam  had  come  into  use.  The  wooden  wedge  was  used  pri- 
marily to  obtain  some  separation  of  the  teeth  in  order  that  the 
cavity  could  be  prepared  and  filled  with  less  mutilation  of  the 
tooth  with  the  file.  The  wedge  was  made  to  serve  another  pur- 
pose also,  which  was  really  the  more  attractive  feature.  The 
soft  tissues  were  carried  away  from  tlie  cavity  margins  by  the 
wedge,  making  it  much  easier  to  keep  it  dry  while  packing  the 
gold.  I  have  often  seen  these  wedges  sticking  out  to  both  buccal 
and  lingual,  with  small  cotton  rolls  lodged  against  them,  and 
these  backed  up  by  larger  rolls  of  cotton,  in  order  to  keep  the 
cavity  dry.  When  the  filling  was  finished  there  was  little  or  no 
septal  tissue  left  between  the  teeth.  In  many  of  the  cases,  every 
bit  of  this  tissue  was  either  crushed  out  or  so  mutilated  that  it 
sloughed  away.  In  those  days,  I  frequently  used  this  plan 
myself  and  carefully  observed  the  results  in  the  extended  sup- 
purations of  the  peridental  membranes.     I  also  saw  an  abun- 

*"  Treatment  and  Prevention  of  Decay  of  tho  Teeth."     1871. 


GINGIVITIS    DUE    TO    INJURIES.  145 

dance  of  this  among  the  patients  of  other  dentists.    Really,  this 
was  creating  havoc  of  the  soft  tissues. 

Discovery  of  the  rubber  dam.  The  rubber  dam  was  dis- 
covered and  made  available  for  protecting  cavities  from  mois- 
ture in  1864.  It  Was  the  suggestion  of  Dr.  S.  P.  Barnum,  who 
spent  very  much  time  in  his  own  office  in  showing  dentists  who 
visited  him  how  to  apply  it.  The  difficulties  men  have  experi- 
enced in  learning  to  use  the  rubber  dam  with  ease  and  facility 
would  be  a  very  amusing  feature  to  me  if  it  were  not  really  so 
serious.  So  many  men  in  practice  and  so  many  students  in  our 
schools  seem  to  have  great  difficulty  in  mastering  the  technic 
of  the  application  of  the  rubl)er  dam,  although  it  is  generally 
very  easily  and  quickly  done  by  those  who  once  get  the  knack 
of  it. 

These  difficulties  held  back  for  many  years  the  general  use 
of  this  best  of  all  means  of  keeping  cavities  dry.  Notwith- 
standing the  development  of  the  many  helps  we  now  have  in 
its  use,  many  men  in  practice  do  not  really  handle  it  well.  For 
this  reason  I  endeavored  in  my  work  on  Operative  Dentistry 
to  so  standardize  the  necessary  movements  as  to  make  the  matter 
very  simple.* 

Physiological  importance  of  tooth  forms.  During  all  of 
this  time,  and  on  up  to  recent  years,  there  was  little  apprecia- 
tion among  dentists  of  the  physiological  importance  of  tooth 
forms  or  of  the  relation  of  these  forms  to  diseases  of  the 
gingivae.  There  was  no  book  on  dental  anatomy  from  which  any 
accurate  information  could  be  gained  regarding  the  forms  of 
the  teeth,  so  that  the  pathological  results  which  might  arise 
from  faulty  forms  could  be  recognized.  For  a  year  or  two 
before  T  wrote  my  book  on  Dental  Anatomy,  in  1891,  I  was  in 
the  habit  of  asking  prominent  dentists  questions  relating  to  the 
anatomy  of  the  teeth.  One  question  frequently  asked  was: 
''Wliat  is  the  difference  between  the  cusps  of  the  upper  first 
molar  and  lower  first  molar?"  T  found  almost  no  one  who  was 
able  to  answer  this  question,  or  even  to  give  the  number  of 
cusps  on  each  of  the  teeth.  The  common  answer  was:  ''Show 
me  the  teeth  and  T  can  tell  the  one  from  the  other."  They  could 
distinguish  an  upper  molar  from  a  lower  molar  in  extracted 
teeth,  even  when  the  roots  were  hidden  from  them,  with  unerring 
accuracy,  but  to  tell  what  the  elements  of  difference  were,  was 
another  question  entirely.     Ignorance  of  the  special  forms  of 

*  Black's  Operative  Dentistry,  Vol.  2,  p.  69. 
16 


146  SPECIAL   DENTAL   PATHOLOGY. 

the  contact  points  for  the  prevention  of  lodgments  was  pro- 
found. In  most  of  the  dental  schools  this  subject  is  now  taught, 
and  the  general  knowledge  of  the  dentist  has  been  wonderfully 
increased  within  the  last  twenty  years. 

In  this  mental  attitude  toward  tooth  forms  men  began  the 
effort  to  restore  the  lost  forms  of  teeth  with  cohesive  gold. 
The  result  was  a  most  miserable  failure  at  first,  and  seemed 
to  gain  in  accuracy  very  slowly.  The  facts  became  clear  enough 
as  I  followed  and  studied  the  results  of  filling  operations  by 
McKellops,  "Webb  and  others  of  the  best  men  of  the  past,  in  the 
manipulative  sense,  whom  the  world  has  known.  I  studied 
their  reproductions  of  form  and  the  results  of  these  betterments 
in  the  protection,  or  failure  of  protection,  of  the  soft  tissues 
investing  the  teeth.  The  manipulation  was  fine.  These  men, 
and  many  others  who  approached  their  manipulative  skill  most 
closely,  could  produce  any  form  they  desired.  The  difficulty 
was  not  in  their  power  of  manipulation,  but  was  because  of 
failure  to  gain  a  correct  conception  of  the  form  required.  As 
our  schools  have  advanced  in  teaching  the  anatomical  forms  of 
the  teeth,  so  has  the  profession  gradually  advanced  in  its  con- 
ception of  the  forms  which  are  necessary  to  give  the  investing 
tissues  the  best  protection. 


GINGIVITIS    DUE    TO    INJURIES.  147 


TREATMENT  OF  GINGIVITIS  DUE  TO  INJURIES. 

ILLUSTRATIONS:    FIGURES  216-225. 

Most  cases  of  gingivitis  due  to  injury  may  be  cured  by  very 
simple  means.  There  is  little  in  the  treatment  of  any  of  these 
conditions  which  may  not  be  accomplished  in  a  comparatively 
short  time.  The  difficulty  is  not  so  much  in  the  technic  to  be 
employed,  as  in  the  fact  that  dentists  generally  have  not  come 
to  recognize  these  inflammations  as  forerunners  of  chronic  sup- 
purative pericementitis.  Many  men  seemingly  are  so  blind  to 
this  relationship  that  no  consideration  whatever  is  given  to 
inflammations  of  the  gingivaB. 

The  gingivitis  and  pericementitis  should  be  clearly  recog- 
nized as  different  stages  of  the  same  disease.  As  previously 
mentioned,  the  connection  between  the  two  has  not  been  appre- 
ciated, by  reason  of  the  fact  that  the  progress  is  so  slow  and  the 
elapsed  time  between  the  beginning  gingivitis  and  the  estab- 
lishment of  an  easily  recognizable  pocket  is  so  great  that  the 
two  are  not  associated. 

The  mouth  examinations  which  have  been  tabulated  reveal 
the  somewhat  startling  fact  that  there  are  areas  of  gingivitis 
in  the  mouths  of  about  ninety-five  per  cent  of  all  adults  and  that 
these  areas  average  more  than  eight  to  each  mouth.  Can  the 
dental  profession  go  calmly  on  with  its  daily  routine  as  here- 
tofore, paying  little  attention  to  these  inflammations,  while  it 
is  at  the  same  time  actually  producing  a  very  fair  percentage 
of  the  whole  number  by  lack  of  consideration  for  the  gingivae 
in  operations  performed?  The  pathology  of  these  lesions  is 
comparatively  simple;  it  should  be  fully  understood  by  every 
dentist.  It  must  become  part  of  the  routine  examination  of  the 
mouth  to  record  the  inflammations  of  the  soft  tissues  and  to 
give  them  the  most  careful  study  and  treatment  in  order  that 
the  health  of  the  mouth  and  of  the  individual  may  be  conserved. 

Really,  the  thought  which  should  be  constantly  uppennost 
in  the  mind  of  every  dentist  in  the  consideration  of  the  treat- 
ment of  these  conditions  is  that  these  areas  of  gingivitis  may  in 
most  cases  be  prevented  by  the  same  simple  treatment  which  is 
employed  to  cure  them  when  tliey  have  occurred.  The  denti^st 
should,   therefore,  come  to  recognize  clearly  those  conditions 


148  SPECIAL.   DENTAL   PATHOLOGY. 

which  cause  these  inflammations  and  do  whatever  may  be  neces- 
sary to  prevent  them.  In  the  entire  field  of  dentistry  no  service 
is  of  greater  value.  If  each  dentist  will  bring  himself  to  real- 
ize that  he  may  be  preventing  the  loss  of  the  entire  denture 
every  time  he  prevents  or  cures  a  slight  gingivitis,  he  will  come 
to  really  appreciate  the  value  of  this  service. 

The  technic  to  be  employed  in  the  individual  case  is  usually 
determined  when  a  proper  diagnosis  is  made.  If  the  inflam- 
mation is  due  to  an  open  contact,  it  is  obvious  that  an  opera- 
tion should  be  performed  which  will  restore  such  a  contact  to 
normal.  If  a  contact  is  not  in  proper  form,  the  malform  should 
be  corrected,  whether  it  be  of  the  tooth  or  a  filling.  If  the 
patient  is,  by  neglect  of  proper  care,  permitting  an  inflamma- 
tion, he  should,  if  possible,  be  made  to  take  an  interest  in  his 
own  welfare  to  the  extent  that  the  difficulty  will  be  remedied. 
If  he  is  causing  inflammation  by  improper  use  of  toothpicks, 
rubber  bands,  etc.,  his  attention  should  be  called  to  such  errors. 
Each  case  is  likely  to  present,  on  careful  study,  a  little  problem 
in  itself.  The  condition  of  the  entire  mouth  must  often  be  taken 
into  consideration.  Oftentimes  the  cause  of  an  inflammation  in 
one  jaw  will  be  found  in  the  opposite  jaw.  Some  suggestions 
as  to  the  various  forms  of  treatment  may  prove  of  interest. 

In  cases  of  lack  of  contact.  If  two  teeth  are  slightly 
separated  on  account  of  the  extraction  of  a  neighboring  tooth, 
a  careful  examination  of  tlie  occlusion  should  be  made  to  deter- 
mine whether  or  not  the  movement  is  apt  to  continue.  If  so,  then 
it  may  be  best  to  make  no  effort  to  restore  the  contacts.  If,  on 
the  other  hand,  certain  contacts  are  open  just  enough  to  catch 
stringy  food  and  thus  keep  up  a  gingivitis,  and  there  is  not  the 
probabilit}^  that  the  separation  will  continue  to  the  point  where 
food  would  not  be  held  between  the  teeth,  the  contact  should 
usually  be  restored  by  a  filling  operation.  If  the  open  contact 
has  been  caused  by  some  abnormality  of  occlusion,  the  abnor- 
mality should,  if  possible,  be  corrected.  In  some  cases,  and  par- 
ticularly in  older  people,  it  will  be  best  to  restore  the  contact 
in  some  other  way,  either  by  grinding  a  little  off  those  cusps 
which  are  holding  the  teeth  apart,  or  by  placing  a  filling.  If  the 
occlusal  wear  of  the  teeth  has  caused  the  opening  of  a  contact, 
a  little  grinding  of  the  cusp  in  the  opposite  .arch  will  usually  be 
sufficient,  as  this  will  permit  the  teeth  to  be  moved  back  into 
contact  by  the  pull  of  the  trans-septal  or  tooth-to-tooth  fibers. 

In  restoring  contacts  by  filling  operations,  a  careful  study 
of  the  widths  of  the  various  interproximal  spaces  should  be 


GINGIVITIS    DUE    TO    INJURIES.  149 

made.  Sometimes  it  will  be  best  to  cut  a  cavity  in  an  undecayed 
tooth,  and  place  a  filling  which  will  be  built  out  to  restore  a 
tight  contact  in  proper  form.  Generally,  however,  some  other 
plan  may  be  followed.  If  there  is  a  proximal  filling  in  a  neigh- 
boring tooth,  it  may  be  replaced  or  built  out  and  the  contact 
made  sufficiently  prominent  to  close  the  open  contact.  For 
example,  if  the  septal  tissue  between  the  first  and  second  bicus- 
pids is  inflamed  on  account  of  an  open  contact,  and  there  are 
no  decays  and  no  fillings  in  either  tooth,  but  there  is  a  mesio- 
occlusal  filling  in  the  first  molar,  this  filling  may  be  replaced 
with  one  having  a  more  prominent  contact,  a  sejjarator  being 
used  to  force  the  second  bicuspid  close  against  the  first  bicuspid. 
Or,  if  the  previously  placed  filling  in  the  molar  is  of  con- 
siderable size,  a  small  cavity  might  be  cut  in  this  filling  without 
removing  it,  and  a  filling  placed,  accomplishing  the  same  result. 

"Weak  contacts  may  be  treated  in  the  same  way,  either  by 
making  the  contour  of  the  proximal  surface  of  one  of  the  teeth 
more  prominent,  or  bj'  building  out  a  filling  in  a  neighboring 
tooth. 

If  there  is  only  a  gingivitis,  these  cases  usually  do  well. 
If.  however,  the  case  has  progressed  until  the  peridental  mem- 
brane has  been  detached,  the  difficulty  of  curing  the  case  by 
building  out  a  contact  is  greatly  increased,  as  will  be  mentioned 
in  detail  later.  Very  often  the  weak  contacts  occur  secondarily 
to  some  trouble  with  a  next  neighboring  contact,  and  both  may 
be  made  right  by  the  operation  rerpiired  for  the  one.  The  loss 
of  the  mesial  surface  of  a  second  molar  by  caries  may  result 
in  a  mesial  movement  of  the  tootli.  thus  permitting  food  to  leak 
through  the  contact  l)etween  the  distal  of  this  tootli  and  the 
third  molar.  The  restoration  of  the  mesial  surface  should  be  so 
made  as  to  restore  both  contacts. 

If  a  ])reviously  i)laced  filling  has  failed  to  restore  the  con- 
tact, it  should  be  either  replaced  or  built  to  form  by  cutting  a 
small  cavity  in  it  and  filling  this.  A  gold  crown  may  sometimes 
be  built  out  in  the  same  way,  by  cutting  a  cavity  and  ])lacing  a 
filling  in  it,  although  it  will  usually  be  necessary  to  replace  such 
a  crown.  Sometimes  the  near-by  teeth  may  be  moved  to  make 
contact  with  a  crown,  by  fillings  which  may  be  required  in  them. 

Danger  of  disturbing  the  occlusfon.  In  all  of  the  above, 
the  occlusion  must  be  carefully  watched.  After  each  operation, 
the  patient  should  be  re(|uestod  to  close  the  teeth  n  number  of 
times,  while  a  cai-eful  watch  is  made  for  movements  of  tho  teeth 
when  the  occlusion  is  pressed  hard,  also  when  it  is  relieved,  lo 


150  SPECIAL    DENTAL    PATHOLOGY. 

see  if  any  contacts  are  opened  and  closed  in  this  way.  The 
movement  of  the  teeth  necessary  to  restore  proper  contacts  in 
one  arch,  may  lead  to  a  disturbance  in  the  opposite  arch,  if  care 
is  not  exercised.  If  any  cusp  strikes  more  noticeably  than  the 
others,  enough  should  be  ground  off  to  relieve  it.  Otherwise  the 
readjustment  of  the  teeth  which  would  occur  within  the  next  few 
days  might  result  in  the  opening  of  some  contact.  It  will  usually 
be  necessary  to  grind  a  little  from  some  particular  portion  of 
the  slope  of  the  cusp,  and  the  occlusion  should  then  be  examined 
again  and  again  to  see  that  this  is  properly  relieved.  This 
grinding  should  not  disturb  the  cusp  as  a  whole.  It  should 
never  be  necessary  to  grind  down  an  entire  cusp. 

For  example,  if  the  lower  bicuspids  were  slightly  separated 
on  account  of  a  flat  mesio-occlusal  filling  in  the  first  molar,  and 
a  separator  should  be  placed  between  the  second  bicuspid  and 
first  molar,  for  the  purpose  of  moving  the  second  bicuspid  hard 
against  the  first  bicuspid  and  holding  it  there  by  building  out  a 
sufficiently  prominent  contact  on  the  first  molar,  it  might  be  that 
the  mesial  movement  of  the  second  bicuspid  would  cause  the 
mesial  slopes  of  its  cusps  to  strike  too  hard  against  the  distal 
slopes  of  the  cusps  of  the  upper  first  bicuspid.  If  this  were  not 
corrected  at  once,  the  tendency  would  be  for  the  upper  first 
bicuspid  to  be  moved  mesially,  possibly  enough  to  weaken  the 
contact  between  it  and  the  upper  second  bicuspid.  Or,  the  lower 
second  bicuspid  might  be  moved  distally  enough  to  reopen  the 
contact  between  it  and  the  lower  first  bicuspid.  The  least  bit  of 
grinding,  which  may  usually  be  done  with  a  disk,  from  the 
mesial  slopes  of  the  cusps  of  lower  second  bicuspid  or  the  distal 
slopes  of  the  cusps  of  the  upper  first  bicuspid  would  prevent 
such  a  disturbance  of  the  occlusion. 

In  cases  of  improper  contact.  If  there  is  an  inflammation 
of  the  septal  gingivjp  due  to  too  broad  a  contact  of  two  teeth, 
there  is  usually  but  one  plan  of  treatment  wliich  will  be  effec- 
tive ;  a  cavity  must  be  cut  in  one  of  the  teeth  and  a  filling  placed 
which  will  be  more  convex  than  was  the  surface  of  the  tooth, 
thus  making  a  rounded  contact  point,  which  broadens  the  tooth 
mesio-distally  and  will  so  touch  the  contact  of  the  approximating 
tooth  that  it  will  not  catch  and  hold  food  debris. 

Malposed  teeth  which  form  improper  contacts  can  in  some 
cases  be  moved  so  that  proper  contacts  will  be  restored.  Some- 
times it  will  be  best  to  cut  cavities  and  make  fillings  of  such 
form  as  to  remedy  the  condition. 

Contacts   which    have   become    flattened   by    interproximal 


1<'IG.  2IG. 


Fig.  218. 


Fig.  216.  Method  of  testing  contacts.  In  testing  a  contact  the  ligature  should 
be  first  carried  through  from  occlusal  to  gingival,  then  the  two  ends  of  the  ligature 
should  be  held  parallel  in  the  occlusal  direction,  as  shown  between  the  two  bicuspids; 
the  distance  between  the  strands  will  indicate  the  bucco-lingual  width  of  the  contact. 
The  two  ends  should  then  be  held  parallel  in  the  buccal  direction,  as  shown  between 
the  second  bicuspid  and  first  molar;  the  distance  between  the  strands  will  indicate 
the  occluso-gingival  width  of  the  contact.  In  either  position,  if  the  parallel  strands 
are  more  than  from  lYj  to  2  mm.  apart,  the  contact  is  too  broad. 

Fig.  217.  Good  and  bad  forms  of  proximal  contacts,  buccal  view.  The  proper 
position  of  the  contact  point  for  bicuspid  and  molar  teeth  is  about  as  shown  in  A, 
just  a  little  to  the  gingival  of  the  marginal  ridges.  The  convexity  of  both  surfaces 
at  this  point  should  generally  change  to  a  slight  concavity  in  the  gingival  direction. 

The  position  of  the  contact  in  b  is  too  far  occlusally.  With  such  a  form  of 
contact,  less  than  the  normal  portion  of  food  will  pass  through  the  embrasures,  and 
the  exposed  portions  of  the  proximal  surfaces  of  the  teeth  will  not  be  normally 
cleansed  in  mastication. 

The  position  of  the  contact  in  c  is  too  far  gingivally.  The  long  approaches 
from  the  occlusal  invite  the  wedging  of  food  between  the  teeth,  with  the  danger  of 
forcing  the  contact  open. 

The  position  of  the  contact  in  d  is  about  right,  but  the  teeth  have  not  been 
separated  to  restore  the  normal  mesio-distal  width  of  the  interproximal  space. 

Fig.  218.  Comparison  of  anterior  and  posterior  interproximal  spaces,  labial  and 
buccal  view.  It  will  be  noticed  that  the  base  is  much  wider  nu'sio-distally  between 
the  bicuspids  and  molars  than  between  tlic  incisors.  Tiiis  would  seem  to  give  the 
more  support  to  the  septal  tissue  between  the  back  teeth.  It  should  be  remembered, 
however,  that  the  line  of  attaclnneut  of  the  gingivae  to  the  incisors  is  very  convex, 
extending  far  towjird  the  incisal  on  llie  proximal  surfaces,  thus  compensating  for  the 
narrower  alveolar  base. 


*16 


Fig.  219. 


Fig.  220, 


Fig.  221. 


Fig.  222. 


Fig.  219.  The  Universal  separator  as  arranged  for  the  smallest  teeth,  or  with 
the  points  closed   together  in  both  directions. 

Fig.  220.  The  separator  opened  full  width  hucco-lingiially  by  turning  the 
adjustment  nuts.  By  means  of  these  nuts  the  adjustnietit  for  the  fitting  of  any  size 
of  tooth  is  made  before  the  separator  is  applied.  It  is  also  opened  a  little  more  than 
half  its  full  width  mesio-distally  by  turning  the  separating  bars.  After  the  separator 
has  been  adjusted  to  the  teeth,  these  separating  bars  are  turned  until  sufficient 
separation  is  made. 

Fig.  221.  The  separator  applied  to  the  bicuspids.  In  tliis  case  the  points  or 
claws  impinge  on  the  soft  tissues  at  the  necks  of  the  teeth;  it  must  be  loosened  at 
once  and  the  separator  propped  up,  as  shown  in  Figure  222. 

Fig.  222.  The  separator  is  propped  up  with  gutta-percha,  modeling  compound 
or  other  suitable  substance  placed  on  the  occlusal  surfaces  of  the  teeth  under  the 
adjustment  bars,  preventing  the  separator  from  slipjung  gingivally  and  injuring  the 
gums.     The  teeth  are  shown  separated. 


Fig.  223. 


Fig.  223.  The  regular  set  of  six  Perry  separators.  It  will  be  observed  that 
these  do  not  have  the  screws  for  bucco-lingual  adjustment.  It  is  therefore  necessary 
to  have  several  instruments  to  fit  the  various  teeth.  Tlie  instrument  marked  A  on  the 
separating  bar  will  generally  fit  between  any  two  molar  teeth;  the  n  between  the 
second  bicuspid  and  first  molar;  the  c  between  the  bicuspids;  the  D  and  e  between 
the  incisors,  the  d  being  for  longer  teeth  than  the  e;    the  F  between  small  bicuspids. 

These  instruments  are  to  be  preferred  to  the  "  Universal  "  shown  in  Figures  219 
and  220,  as  they  are  more  easily  placed,  are  steadier  and  nuich  less  in  the  way. 


Fig.  224, 


Fig.  225. 


Fig.  224  shows  tlie  matri.x  for  an  iiiiialjjaiu  filling  held  in  position  by  the 
separator.  This  fovin.  which  is  quite  fully  explained  by  the  illustration,  is  a  {]food 
and  efficient  method  of  using  the  combination  of  the  two  instruments.  When  the 
separator  has  been  placed  on  the  teeth  and  tightened  just  enough  to  stay  well  in 
|)lace,  the  matrix  is  easily  forced  between  the  tooth  and  the  claws  of  the  separator 
and  is  then  firmly  held  and  tightened  against  the  tooth.  Or  the  matrix  may  be  tied 
in  place  and  the  separator  applied  later. 

Fig.  22.5.  When  the  filling  has  been  placed  and  the  occlusal  surface  trimmed  to 
form,  and  some  time  has  been  given  for  the  amalgam  to  become  hard,  the  separator 
is  loosened  and  removed;  then  the  ends  of  the  matrix  are  straightened  out  to  the 
buccal  and  lingual,  as  shown.  The  separator  is  then  replaced  and  tightened  until  the 
grasp  of  the  two  teeth  on  the  matrix  is  loosened.  The  matrix  is  then  removed  and 
the  proximal  portion  of  the  filling  trimmed  to  form.  Finally  the  separator  is 
removed. 


GINGIVITIS    DUE    TO    INJURIES.  151 

wear  must  be  treated  the  same  as  teeth  having  abnormally  flat 
contacts;  the  proximal  surfaces  must  be  made  sufficiently  con- 
vex by  filling  operations.  Oftentimes  the  placing  of  one  filling 
with  a  prominent  contact  in  the  bicuspid  and  molar  region  will 
be  sufficient  to  tighten  all  of  the  contacts  of  the  side  so  that 
impactions  will  be  prevented.  In  keying  up  the  arch,  the  fact 
must  be  kept  in  mind  that  the  interproximal  wear  of  the  teeth 
will  shorten  the  distance  around  the  arch  from  one  third  molar 
to  the  other  third  molar  about  one-third  of  an  inch  by  the  time  a 
person  is  forty  years  of  age.  Of  this  wear,  much  the  greater 
part  occurs  in  the  bicuspid  and  molar  region,  where  the  heaviest 
mastication  is  done. 

The  most  frequent  cases  of  flat  contacts  are  fillings  and 
crowns.  Most  such  fillings  and  porcelain  crowns  can  be  trimmed 
to  proper  form  by  placing  a  separator  for  a  moment  to  get  room 
for  the  finishing.  This  is,  of  course,  what  should  have  been  done 
when  the  operations  were  made  originally. 

Other  conditions.  Little  need  be  said  regarding  the  treat- 
ment indicated  in  those  cases  in  which  a  cavity  edge  or  a  filling 
margin  is  causing  an  irritation  of  the  overlying  tissue.  If  sharp 
edges  of  cavities  are  causing  inflammation,  the  placing  of  proper 
fillings  will  remedy  the  trouble.  If  filling  margins  are  not 
smooth,  they  should  be  made  so  by  trimming  if  overfull;  by 
adding  to  or  replacing  fillings  which  are  not  full  enougli. 
Crowns  which  do  not  properly  fit  the  root  end,  or  which  for  any 
other  reason  cause  inflammation,  should  often  be  removed  and 
new  crowns  made.  Any  procedure  should  be  undertaken  which 
promises  to  permit  the  gingivae  to  return  to  a  healthy  condition. 

More  careful  study  of  cases  necessary.  The  successful 
treatment  for  the  prevention  or  cure  of  the  cases  of  gingivitis 
which  are  constantly  presenting,  involves  the  more  careful 
study  by  the  profession  of  all  of  these  slight  inflammntions;. 
The  discovery  of  each  area  of  inflammation  should  lead  to  the 
immediate  investigation  of  the  cause  and  to  the  operation  neces- 
sary for  its  correction.  By  following  this  plan,  each  operator 
will  soon  come  to  have  a  better  understanding  of  the  results  of 
his  errors  in  technic,  of  his  neglect  of  some  little  thing,  of  his 
abuse  of  the  tissue  in  the  application  of  the  rubber  dam,  in  fin- 
ishing and  polishing  operations,  etc.,  so  that  he  may  avoid  these 
in  the  future. 

This  abuse  of  the  gingiv.T  during  operations  in  the  manage- 
ment of  dental  carles  has  been  common  ever  since  I  have  been 
in  practice.    It  has  become  so  fixed  in  the  minds  of  dentists  that 


152  SPECIAL   DENTAL   PATHOLOGY. 

it  will  require  the  combined  and  long-continued  efforts  of  all 
of  the  best  men  in  practice  to  eradicate  it.  Many  years  of  effort 
have  been  expended  to  bring  the  filling  of  cavities  of  decay  to 
the  present  standard  of  efficiency,  and  many  more  will  be 
required  to  bring  a  majority  of  dentists  up  to  the  efficiency  of 
the  more  skilful  men  of  the  present  time.  The  correction  of  the 
abuses  of  the  gingiva?  will  necessarily  follow  a  similar  slow 
development.  This  should  not  be  regarded  as  a  discouragement. 
The  accomplishment  will  come  in  gradual  improvements,  and 
will  come  with  time. 

In  this  the  most  rigid  rules  of  looking  after  what  is  now 
regarded  as  the  minor  details  of  practice  will  be  necessary. 
Every  injury  to  the  gingivae  should  have  a  place  in  the  record 
of  examinations.  The  treatment  of  these  and  the  outcome  of 
each  case,  as  determined  by  later  examinations,  should  be 
recorded.  In  this  way  men  may  soon  have  records  of  these 
matters  which  will  be  of  great  practical  value  and  many  serious 
cases  of  disease  will  be  avoided. 

In  a  similar  way  dentists  must  study  those  cases  in  which 
patients  are  permitting  or  causing  inflammations,  either  by  lack 
of  care  in  cleaning  operations  or  by  errors  in  their  efforts. 
These  will  be  considered  in  detail  under  the  discussion  of  Mouth 
Hygiene.  It  need  only  be  added  here  that  it  should  be  a  part 
of  the  dentist's  duty  to  carefully  scrutinize  the  mouth  of  each 
patient  at  regular  intervals  for  the  particular  purpose  of  noting 
and  pointing  out  areas  of  inflammation  which  may  be  eliminated 
by  better  care  by  the  patient.  The  dentist  must  put  himself 
into  this  work  with  an  earnestness  which  will  command  the 
interest  and  cooperation  of  the  patient. 

An  EXACT  METHOD  OF  SEPAKATION  ESSENTIAL  TO  SUCCESS  IN  BUILD- 
ING PROPER  CONTACTS. 

As  early  as  1846,*  possibly  much  earlier,  rul)ber  wedges 
were  used  to  separate  teeth  to  gain  space  for  the  ])lacing  of 
y)roximal  fillings  in  the  front  teeth.  As  has  been  mentioned,  it 
was  the  common  practice  to  drive  wooden  wedges  between  the 
back  teeth  for  the  same  purpose  fifty  years  ago.  Both  methods 
were  used  for  many  years,  and  the  rul)l)er  wedge  is  used  to  a 
considerable  extent  yet.  The  wooden  wedge  was  both  very  pain- 
ful and  terribly  destructive  to  the  se]ital  tissues.  The  rubber 
wedge  often  caused  the  teeth  to  become  j^ainfully  sore  as  the 

*  The   Surgical,    Meohanieal    and    Medit-al    Treatniont    of   the    Teeth,    by    .Tames 
Rnbinson,  second  edition,  1846,  p.  107. 


GINGIVITIS    DUE    TO    INJURIES.  153 

result  of  the  continuous  pressure,  and  the  soft  tissues  were  fre- 
quently injured.  The  soreness  of  the  teeth  occasionally  made 
it  necessary  to  postpone  filling  operations,  or  if  they  were  under- 
taken while  the  teeth  were  sore,  much  pain  was  inflicted  and 
oftentimes  the  operations  could  not  be  properly  performed. 
Other  methods  were  unsatisfactory  for  one  reason  or  another. 
People  came  very  justly  to  have  a  horror  of  the  separation  of 
the  teeth. 

To-day  we  separate  teeth  principally  for  the  purpose  of 
restoring  proper  contacts.  With  our  present  methods  of  cavity 
preparation,  separation  for  convenience  of  access  is  generally 
unnecessary  for  fillings  in  the  back  teeth,  and  only  occasionally 
in  the  front  teeth.  Therefore,  only  a  little  movement  of  the 
teeth  is  necessary  —  just  enough  to  permit  of  trimming  and 
polishing  and  still  leave  a  proper  contact.  It  is  understood  that 
if  the  teeth  have  moved  together  more  closely  than  they  should 
normally  be,  additional  separation  is  necessary.  Several  forms 
of  contacts  and  a  method  of  testing  the  widths  of  contacts  are 
shown  in  Figures  216,  217  and  218. 

The  Perry  separator.  In  1879  Dr.  Stafford  G.  Perry* 
invented  a  separator  which  is  so  designed  that  the  teeth  may  be 
lifted  apart  without  the  slightest  injury  to  the  soft  tissues  and 
with  little  or  no  discomfort  to  the  patient.  Separation  may  he 
gained  at  the  same  sitting  at  which  the  filling  is  placed,  and  in 
the  placing  of  gold  fillings,  the  appliance  really  makes  the  opera- 
tion easier  for  the  patient  by  holding  the  tooth  being  filled  tightly 
against  the  next  tooth  in  the  arch,  thus  gaining  its  support  in 
resisting  the  force  of  the  mallet.  In  placing  amalgam  fillings, 
the  separation  is  gained  and  the  matrix  held  tightly  at  the  gin- 
gival by  this  appliance.  For  the  setting  of  inlays,  the  separator 
is  not  always  necessary,  but  there  is  often  a  decided  advantage 
in  lifting  the  teeth  apart  just  a  little.  The  Perry  separator  and 
its  application  are  illustrated  in  Figures  219  to  225. 

It  is  not  within  the  scope  of  this  book  to  do  more  than 
emy')hasize  the  imperative  need  of  serious  study  of  the  best 
methods  necessary  to  proper  contact  restoration.  The  Perry 
separator  is  the  best  instrument  that  I  know  of  for  this  purpose 
to-day.  This,  or  some  similar  appliance  having  four  jaws  which 
may  be  set  against  the  teeth  without  impinging  on  the  soft  tis- 
sues, should  be  in  the  equipment  of  every  dentist  and  should  be 
used  for  practically  every  proximal  filling  operation.     In  con- 

»  Dental  Cosmos,  Vol.  21,  1879,  p.  253. 


154  SPECIAL    DENTAL   PATHOLOGY. 

nection  with  the  pkicing  of  amalgam  fillings,  it  should  bo  applied 
"when  the  filling  is  placed  and  again  when  it  is  polished.  Satis- 
I'actoiy  contact  restorations  can  not  be  made  otherwise. 

The  study  of  contact  forms  of  both  teeth  and  fillings  should 
be  a  constant  one  by  every  dentist.  In  the  examination  of  each 
mouth  every  contact  should  be  tested  and  a  record  made  of  those 
which  are  not  normal.  If  the  contact  is  not  right,  there  will 
usually  be  an  inflammation  of  the  septal  tissue  which  can  not 
recover  until  the  faulty  contact  is  corrected.  In  this  constant 
care  of  contacts  lies,  in  considerable  measure,  the  secret  of  the 
I>revention  of  peridental  disease. 

Dentists  who  have  not  mastered  the  technic  of  the  use  of 
the  separators  of  the  Perry  type  should  begin  at  once  the  effort 
to  do  so  and  continue  until  they  can  easily  place  these  separators 
in  practically  anj^  position  in  the  mouth,  without  serious  dis- 
comfort to  the  patient.  The  technic  of  application  is  given  in 
the  descriptions  of  the  illustrations,  Figures  219  to  225. 

This  separator  catches  the  teeth  near  the  gingivae  with  its 
jaws,  and  the  teeth  can  be  separated  to  any  extent  that  may  be 
desired,  by  the  slow  motion  of  the  screws  on  the  sides.  Teeth 
which  are  firmly  set,  as  the  molars,  will  often  require  that  con- 
siderable force  be  applied  in  turning  the  screws.  Attention  is 
called  to  the  fact  that  the  spring  in  the  jaws  of  the  separator 
will  exert  a  constant  pull  on  the  teeth  and  may  cause  some  addi- 
tional movement  within  a  few  minutes.  If  the  separator  is 
applied  during  the  latter  part  of  the  cavity  preparation,  and,  if 
the  spring  of  the  separator  during  the  placing  of  a  filling  has 
not  carried  the  teeth  far  enough  apart,  a  little  further  tighten- 
ing of  the  screws  will  give  space  for  the  final  finishing  of  a  gold 
filling.  Single-rooted  teeth  move  more  easily  than  the  molars 
and  care  must  be  taken  in  tightening  the  screws  upon  these,  for 
they  may  be  carried  much  farther  apart  than  is  desirable.  One 
should  acquire  a  very  accurate  conception  of  the  force  retjuired 
to  move  the  teeth  with  such  a  separator  and  learn  to  use  only 
the  amount  of  force  necessary  in  the  individual  case.  For  the 
patient,  this  mode  of  separation  is  the  easiest  that  has  ever 
been  devised.  The  separation  is  made  and  the  operation  com- 
pleted at  one  sitting.  There  is  no  injury  to  the  membranes 
about  the  teeth  and  the  teeth  are  not  sore,  as  they  often  are  with 
other  methods. 

After  the  teeth  are  allowed  to  drop  on  their  new  contacts, 
and  the  occlusion  is  carefully  examined  and  corrected,  if  need 
be,  as  has  been  directed,  no  discomfort  of  consecjuence  should 


GINGIVITIS   DUE   TO   INJURIES.  155 

be  felt  and  mastication  may  go  on  with  these  teeth  immediately 
afterward. 

To  accomplish  all  of  this,  however,  requires  the  develop- 
ment of  skill  in  the  application  of  the  separators,  the  prevention 
of  injury  to  the  gingivae  by  them  and  the  use  of  the  proper  force 
in  the  tightening  of  the  screws  in  each  case. 

It  will  be  of  interest  to  refer  to  one  case  in  which  it  was 
necessary  to  secure  considerable  movement  of  the  teeth  in  order 
to  restore  a  proper  contact  and  the  full  mesio-distal  width  of 
the  interproximal  space.  A  young  lady  who  had  been  a  patient 
of  mine  since  childhood,  left  me  and  went  to  her  husband's 
dentist  after  her  marriage.  Several  years  later  she  returned 
complaining  of  soreness  of  the  tissue  between  a  second  bicuspid 
and  first  molar.  There  was  a  mesio-occlusal  filling  in  the  molar 
which  was  flat  on  the  mesial  surface  and  did  not  quite  make 
contact  with  the  bicuspid,  and  the  space  was  packed  with  food 
at  each  meal.  The  molar  had  moved  mesially  so  that  it  was 
necessary  to  gain  considerable  space  to  restore  the  normal  con- 
tour of  the  tooth. 

The  filling  was  removed  and  a  Perry  separator  was  applied. 
Pieces  of  gutta-percha  were  warmed  and  placed  between  the 
occlusal  surfaces  of  the  first  bicuspid  and  second  molar  and  the 
bows  of  the  appliance  where  these  crossed  over  these  surfaces 
from  buccal  to  lingual.  (See  Figure  222.)  The  gutta-percha 
was  allowed  to  harden  before  the  separating  screws  were 
tightened.  This  use  of  gutta-percha  is  particularly  important, 
as  the  jaws  would  otherwise  be  inclined  to  slip  in  the  gingival 
direction  with  the  increase  of  the  pressure,  and  thus  not  only 
injure  the  gingivae,  but  cause  unnecessary  pain.  Then  the  screws 
were  tightened  slowly  until  it  was  thought  that  as  much  pres- 
sure was  put  on  as  was  prudent  to  use.  The  cavity  was  then 
filled  with  base  plate  gutta-percha,  which  was  packed  solidly 
against  the  distal  surface  of  the  second  bicuspid.  In  doing  this 
an  instrument  was  placed  between  the  teeth  to  the  gingival  of 
the  gingival  margin  of  the  cavity  and  was  held  firmly  in  place 
while  the  gutta-percha  was  built  over  it;  the  instrument  was 
then  removed.  By  this  means  the  crowding  of  the  gutta-percha 
upon  the  septal  tissue  was  avoided. 

After  the  gutta-percha  had  hardened,  the  separator  was 
removed.  Thus  the  gutta-percha  held  the  space  which  had  been 
gained  by  the  separator.  The  patient  was  directed  to  use  this 
tooth  as  much  as  possible  in  mastication  and  to  return  four  days 
later,  at  which  time  the  same  separator  was  placed,  and  again 


156  SPECIAL   DENTAL   PATHOLOGY, 

it  was  tightened  up  very  slowly  and  the  teeth  carried  as  much 
farther  apart  as  could  reasonably  be  done.  The  gutta-percha 
filling  was  warmed  slightly  with  a  burnisher  and  again  packed 
hard  against  the  bicuspid.  The  patient  was  again  dismissed 
for  a  few  days.  This  was  repeated  to  the  fourth  time,  when  the 
separation  was  sufficient,  the  tooth  having  been  moved  to  its 
normal  position. 

Then  the  patient  was  instructed  to  do  heavy  chewing  on 
that  side  of  the  mouth,  in  order  to  have  the  membranes  of  the 
teeth  toned  up  to  their  full  vigor  by  usage  in  mastication,  as 
T  intended  to  place  a  gold  filling,  and  desired  to  have  the  peri- 
dental membrane  in  the  best  condition  to  withstand  the  mallet- 
ing.  The  patient  could  now  chew  without  any  discomfort  or 
injury  to  the  gingiva  from  food  wedging  into  the  interproximal 
space. 

Three  weeks  after  the  separation  was  last  applied,  the 
cavity  was  filled.  The  filling  was  made  sufficiently  broad  mesio- 
distally,  with  a  good  contact.  The  gold  which  formed  the  contact 
was  very  thoroughly  condensed,  in  order  that  it  might  with- 
stand the  wear  which  would  occur  from  the  liucco-lingual  move- 
ment of  the  teeth  in  chewing.  The  separator  was  in  position 
while  the  filling  was  placed  and  held  the  first  molar  hard  against 
the  second  molar,  thus  securing  the  support  of  the  second  molar 
against  the  malleting.  In  finishing  the  filling,  the  separator  was 
tightened  a  little  more  to  facilitate  the  finishing  of  the  contact 
point. 

Subsequently  the  patient  was  able  to  use  this  side  of  the 
mouth  normally  in  mastication  and  without  the  slightest  dis- 
comfort. This  is  the  best  plan  of  which  I  know  for  the  manage- 
ment of  cases  of  this  kind.  It  should  be  understood  that  the 
separation  may  be  gained,  the  filling  placed  and  finished  in  one 
sitting  in  practically  all  cases  in  which  the  teeth  have  not 
dropped  together. 

In  the  illustrations  of  the  Perry  separators,  it  will  be  noted 
that  there  is  a  set  of  six  instruments,  shown  in  Figure  223,  which 
are  made  of  different  sizes  to  fit  various  positions  about  the 
mouth,  while  a  "universal"  separator,  shown  in  Figures  219  and 
220,  has  been  more  recently  designed  to  take  the  place  of  the 
other  six.  This  universal  instrument  has  screws  for  adjusting 
the  bucco-lingiial  width.  It  is  larger  than  those  of  the  regular 
set;  it  is  also  more  difficult  to  adjust  and  is  more  in  the  way 
because  of  its  bulkiness.  I  would  strongly  advise  the  use  of  the 
*set  of  six  in  i)reference  to  the  universal  instrument. 


GINGIVITIS    DUE    TO    INJURIES.  157 

In  addition  to  the  regular  set  of  six,  there  is  an  additional 
set  of  six  "specials,"  designed  for  unusually  large  teeth.  These 
are  needed  only  occasionally,  but  are  desirable  and  serve  to  make 
one  master  of  practically^  every  situation. 

Occasionally  a  case  presents  in  which  the  crown  of  a  tooth 
has  been  lost  by  caries  and  the  teeth  on  either  side  have  moved 
until  they  overlap  the  root  between  them.  A  very  simple  method 
of  gaining  separation  in  such  cases  is  to  substitute  a  pair  of 
extra  long  separating  screws  in  a  Perry  separator,  so  that  the 
jaws  may  be  applied  to  the  teeth  on  either  side  of  the  root  and 
move  them  both  away  from  the  root,  holding  the  space  gained 
at  each  application  by  the  use  of  gutta-percha,  as  in  the  case 
mentioned  above  in  which  slow  separation  was  employed. 


17 


158  SPECIAL   DENTAL.   PATHOLOGY. 


CHRONIC  SUPPURATIVE  PERICEMENTITIS 

ILLUSTRATIONS:     FIGURES  226-264. 

Thus  far  we  have  given  our  attention  to  the  various  com- 
mon causes  and  forms  of  gingivitis.  We  have  also  noted  the 
gradual  destruction  of  all  of  the  investing  tissues  of  the  teeth 
by  deposits  of  salivary  calculus.  We  are  now  to  consider  that 
condition  in  which,  as  a  result  of  a  preceding  gingivitis,  there 
occurs  a  detachment  of  the  peridental  membrane  from  the 
cementum,  beginning  at  the  gingival  line,  forming  a  pus  pocket 
alongside  the  root.    This  is  chronic  suppurative  pericementitis. 

As  previously  mentioned,  I  applied  the  term  phagedenic 
pericementitis  to  this  condition  in  1882.  The  word  phagedenic 
is  derived  from  the  Greek  phagein,  which  means  to  destroy  by 
eating.  In  pathology  this  word  was  formerly  much  used  to 
designate  a  suppurative  condition  in  which  the  tissues  were 
progressively  destroyed;  as  a  phagedenic  ulcer.  Phagedenic 
pericementitis,  therefore,  refers  to  that  condition  in  which  the 
peridental  membrane  is  gradually  destroyed  by  suppurative 
inflammation.  However,  the  term  chronic  suppurative  peri- 
cementitis describes  the  condition  as  accurately  and  is  more 
readily  understood.  In  ordinary  usage  the  term  suppurative 
pei'icementitis  will  be  sufficient. 

I  am  quite  certain  that  this  disease  was  destroying  many 
dentures  in  ancient  days,  and  has  continued  to  do  so  to  the 
present  time,  yet  recognition  of  this  fact  has  come  in  compara- 
tively recent  years.  I  was  surprised  on  reviewing  Dr.  Reh- 
winkel's  famous  article  before  the  American  Dental  xVssociation 
in  1877,  to  find  that  he  made  no  mention  of  such  a  form  of  dis- 
ease. If  he  had  known  of  these  pus  pockets  it  seems  certain  that 
he  would  have  mentioned  them.  Neither  is  there  any  evidence 
that  Dr.  Riggs  recognized  this  as  a  separate  form  of  disease.  It 
now  seems  probable  that  the  descriptions  of  pus  pockets  which 
I  wrote  in  1882,  and  the  figures  illustrating  them,  published  in 
the  American  System  of  Dentistry  in  1886,  constituted  the  first 
detailed  description  of  them,  and  yet  this  is  rather  difficult  for 
me  to  believe.  I  had  recognized  this  form  of  disease  in  a  vague 
way  many  years  earlier,  but  did  not  have  that  mental  grasp  of 


CHRONIC    SUPPURATIVE    PERICEMENTITIS,  159 

the  condition  as  a  whole,  which  enabled  me  to  describe  it  fully. 
Many  others  no  doubt  had  similar  impressions.  (See  Figures 
226-264.) 

Up  to  the  present  time  very  few  men  have  really  studied 
the  beginnings  of  the  formation  of  pus  pockets  alongside  the 
roots  of  teeth.  The  beginning  of  these  is  by  many  dentists  still 
being  attributed  to  deposits  of  salivary  calculus.  Many  have 
also  regarded  the  deposits  of  serumal  calculus,  on  that  part  of 
the  root  which  has  been  stripped  of  its  membrane,  as  the  prin- 
cipal cause  of  the  continuance  of  the  inflammatory  movement. 
The  fact  seems  to  be  that  neither  of  these  propositions  is  true. 
With  the  exception  of  the  pus  pockets  caused  primarily  by 
serumal  calculus  in  the  subgingival  space,  which  have  been 
described,  it  is  very  rare  that  a  pus  pocket  is  caused  by  any 
form  of  calculus.  In  these  pockets  the  deposit  of  calculus  is 
a  result  of  the  inflammation  and  suppuration.  It  is  derived 
from  the  serum  escaping  from  the  tissues  in  the  inflamed  and 
suppurating  state  —  a  result  of  the  condition,  not  a  cause  of  it. 
It  seems  safe  to  say  that  closer  studies  in  the  future  will  give 
these  propositions  general  credence.  They  will  be  discussed 
more  in  detail  later. 

As  a  general  proposition  dentists  have  not,  up  to  the  pres- 
ent time,  found  or  recognized  those  conditions  leading  to  the 
formation  of  pus  pockets.  The  treatment  which  has  been  given 
has  been  instituted  after  the  disease  has  been  fully  under  way, 
instead  of  at  a  time  when  it  can  be  prevented,  as  it  should  be. 
The  failure  to  connect  the  causes  with  the  disease  has  been  due 
largely  to  the  great  resistance  offered  by  the  tissues  and  the 
very  slow  progress  of  the  disease.  It  is  often  many  years  from 
the  beginning  gingivitis  until  the  case  progresses  to  the  point 
where  there  is  an  actual  detachment  of  the  peridental  membrane. 
The  gingivitis  often  causes  little  discomfort  to  the  patient; 
there  may  be  no  complaint,  and  the  dentist,  whether  he  notices 
the  inflamed  area  or  not,  does  nothing  to  correct  it.  When  the 
case  has  reached  the  serious  stage  of  a  definitely  formed  pus 
pocket,  the  original  gingivitis  has  been  forgotten. 

In  order  to  illustrate  the  progress  of  the  disease.  Figures 
226  to  230  on  the  colored  plate  have  been  arranged  to  show  the 
steps  from  the  initial  gingivitis  to  the  formation  of  deep  pockets 
and  a  lateral  abscess.  If  one  will  imagine  these  to  be  progres- 
sive stages  of  a  single  case  of  many  years  duration,  a  l)etter 
idea  may  be  gained  of  the  relationship  of  the  gingivitis  to  the 
formation  of  the  pus  pocket. 


160  SPECIAL    DENTAL    PATHOLOGY, 


Figs.  226  to  231.  Eeproductiona  of  cases  of  gingivitis  and  pericementitis  in 
various  stages. 

Fig.  226.  It  will  be  noticed  that  there  is  just  a  little  inflammation  of  the  septal 
gingiva  between  the  first  and  second  molars.  This  was  due  to  leakage  of  food  through 
a  weak  contact ;  there  was  no  decay.  It  should  be  recognized  that  every  such  inflam- 
mation may  be  the  forerunner  of  a  ease  of  chronic  suppurative  pericementitis,  which 
may  involve  the  entire  denture.  Here  is  the  opportunity  to  cure  the  gingivitis  and 
■prevent  the  pericementitis. 

Fig.  227.  Occlusal  view  of  a  case  similar  to  that  shown  in  Figure  226.  In  this, 
food  impaction  occurred  between  the  bicuspids.  There  is  a  little  swelling  of  the 
tissue  of  both  buccal  and  lingual  embrasures  with  a  depression  between.  A  simple 
operation  to  restore  a  proper  contact  will  result  in  the  prompt  disappearance  of  the 
gingivitis.  If  neglected  it  will  progress  to  the  condition  shown  in  Figures  228,  229 
and  possibly  230. 

Fig.  228.  Buccal  view  of  a  case  in  which  an  open  contact  permitted  food  lodg- 
ment and  resulted  in  the  destruction  of  much  of  the  septal  tissue  and  detachment  of 
the  peridental  membrane  from  the  distal  surface  of  the  cuspid.  This  case  has  already 
progressed  so  far  that  a  cure  is  out  of  the  question.  Most  such  cases  will  gradually 
progress  with  the  best  of  treatment. 

Fig.  229.  A  case  in  which  the  open  contact  has  resulted  in  the  complete  destruc- 
tion of  the  septal  gingiva  and  the  formation  of  a  deep  pocket  between  the  first  molar 
and  second  bicuspid.  The  trans-septal  fibers  have  all  been  destroyed  and  there  is 
little  hope  of  maintaining  a  contact.  The  inflammation  between  these  teeth  will 
usually  cause  neighboring  contacts  to  open,  as  described  in  the  text. 

Fig.  230.  A  lateral  abscess,  which  occurred  in  a  case  similar  to  that  shown  in 
Figure  229.  Instead  of  the  pus  escaping  alongside  the  tooth,  it  penetrated  the  soft 
tissue  and  an  abscess  developed.  The  swelling  caused  the  soft  tissue  to  fill  the  septal 
space.  After  the  acute  symptoms  have  passed,  the  tissue  of  this  space  will  resemble 
that  shown  in  Figure  263. 

Fig.  231.  A  case  in  which  an  open  contact  between  the  upper  central  and  lateral 
incisors  had  caused  a  recession  of  the  septal  gingiva.  Such  cases  usiially  progress  to 
the  destruction  of  the  peridental  membrane,  if  the  contact  is  not  restored. 


10.   22fi. 


Fig.  227, 


Fig.   22S. 


Fig.  229. 


Fk;.   2;'.( 


Fi(i.   231. 


♦17 


Fig.  232. 


Fig.  2X]. 


Figs.  2.S2,  2.3H.  J'aiiorainic  ia(li()i;raiiliic  \  icw  of  a  iioriiial  (Ifiitiiic,  tci  show 
osi)Ocially  the  height  of  the  hoiiy  alveohir  septi  between  the  teeth,  for  coiiiiiafison 
witli  other  radiographs  in  whicii  destruetion  of  bone  has  oecurred. 

These  and  the  otlier  |)anoraniie  radiograpliic  illustrations  in  this  book  were  pre- 
pared l)y  Dr.  Arthur  I).  Pdack.  They  are  made  by  taking  a  full  set  of  radiographs 
on  the  ordinary  small  films.  From  each  of  these  a  4  by  6  inch  enlargement  was 
made.  The  enlarged  photographs  were  cut  and  patched  together,  and  then  repro- 
diicf(i  hv  the  eiitrraver. 


Fig.  234. 


Fig.  235. 


Figs.  234,  235.  runorainie  ia(li(if,M;ii)liic  views  of  tlio  iiinx-r  and  Iowim-  jaws  in 
a  case  of  chronic  suppurativo  pericoiiieiititis  of  long  standing.  Tliis  patient  had 
snffored  from  gout  for  five  vears.  The  right  foot  was  first  swollen  and  was  very 
painful  In  subsequent  attacks  the  ankle  \vas  involved.  The  patient  stated  that 
e.xcept  for  this,  he  had  never  been  sick  a  day.  One  lower  incisor  had  become  so 
loose  that  it  was  rernoved  with  the  fingers.  Pressure  upon  tlie  gums  caused  pus  to 
exude  about  the  necks  of  many  of  the  teeth.  It  was  advised  that  all  of  the  teeth 
be  extracted. 


bl7 


Fk;.  ii;;i 


Fig.  237. 


Fig.  236.  Normal  peridental  membrane.  Section  showing  fibers  attached  to  the 
cementum  from  the  gingival  lino  almost  to  the  apex  of  the  root.  The  section  is  not 
qnitc  parallel  with  the  long  axis  of  the  tooth  and  is  a  little  to  one  side  of  the  apex 
of  the  root.  The  fibers  which  pass  upward  into  the  gingiva^,  those  which  pass  to  the 
crest  of  the  alveolar  process,  and  those  which  pass  directly  from  the  cementum  to  the 
bone  are  clearly  shown  as  a  practically  solid  mass  from  the  gingival  line  to  the  end  of 
the  root.     Photograph  by  Dr.  F.  B.  Noyes. 

Fig.  237.  Normal  peridental  membrane.  lliglicr  magnification  of  about  the 
gingival  half  of  Figure  1.  The  fibers  are  shown  more  distinctly.  The  row  of  cemento- 
blasts  may  bo  soon  lying  along  the  surface  of  the  cementum.  These  cells  occupy  most 
of  the  space  between  the  fibers  as  the  latter  enter  the  cementum.  Photograph  by 
Dr.  F.  B.  Noyes. 

Figures  236  to  240  were  first  published  in  an  article  bv  Dr.  .\rtluir  D.  Black  in 
the  Western  Dental  Journal,  Vol.  28,  October,  1914,  p.  1. 


Fig.  238. 


Fig.  238.  Section  tliroiiyh  root  and  labial  alv(>olar  process  of  an  iqjper  central 
incisor,  sliowing  about  one-fourth  of  the  root  close  to  the  apex.  Patient  forty  years 
of  age.  The  periilontal  membrane  on  the  lingual  side  of  this  tooth  was  detached 
almost  to  the  apex  and  the  pocket  extended  around  on  both  the  mesial  and  distal 
sides  of  the  root,  but  was  not  so  deep  on  either  the  mesial  or  distal,  as  on  the  lin;jual. 
This  tooth  was  extracted  by  Dr.  Arthur  D.  Black,  May  27,  1912.  With  the  patient 
under  nitrous  oxid  anesthesia,  two  incisions  were  made  through  the  labial  gum 
parallel  to  the  length  of  the  root  and  a  third  incision  was  made  horizontally  above 
the  position  of  tlie  apex,  meeting  the  other  two.  The  alveolar  process  was  cut  through 
with  a  drill  in  tlie  engine  along  the  same  lines,  and  the  tooth  with  the  labial  peri- 
dental membrane,  alveolar  process  aiul  gum  tissue  were  all  removed  together.  This 
illustration  should  be  compared  with  Figures  236  and  237.  Marked  changes  have 
taken  place  in  both  the  peridental  membrane  and  alveolar  process.  Many  of  the 
fibers  have  disappeared.  One  strong  bundle  of  fibers  remains  toward  the  apex  of  the 
root;  another  fairly  good  bundle  is  seen  near  the  top  of  the  illustration.  Section 
prepared  and  photographed  by  Dr.  F.  B.  Noyes. 


Fig.  239. 


J'JG.    l'4(». 


I''i(i.  li.'Jil.  ScctiuM  tlii(>ii;;li  soft  lissuc  (p\crlyiny  it  ilci'ii  p'X'k'^'t  I'l  iiiMiiy  y<'ars 
standing  on  the  labial  side  of  tlic  root  of  a  lower  left  cuspid;  from  about  the 
middle  of  the  length  of  the  root.  Patient  sixty-five  yoars  of  age.  Tissue  cut  away 
by  Br.  Arthur  1).  Black  on  September  29,  1913.  Normally  the  crest  of  the  alveolar 
process  should  be  present  in  a  section  cut  in  this  position.  The  bone  has  all  dis- 
appeared, as  have  practically  all  of  the  fibers  of  the  peridental  membrane.  Section 
prepared  by  Dr.  H.  A.  Potts,  photographed  by  Dr.  F.  B.  Noyes. 

Fig.  240.  High  magnification  from  very  near  the  center  of  section  shown  in 
P^igure  239.  The  normal  cells  of  the  tissue  have  practically  all  disappeared  and 
have  been  replaced  by  inflammatory  tissue.  By  what  process  of  treatment  might  we 
expect  to  liave  a  regeneration  of  those  elements  nec(>ssary  to  a  stal)le  reattachment  to 
the  cementum?  Section  prepared  by  Dr.  H.  A.  Potts,  photographed  by  Dr.  F.  B. 
Noyes. 


Wu:      "4  1 


Fk;.  '-'41.  Scctidii  tliii)ii<;li  soft  tissue  ovorlyiiiji;  a  pocket  mi  llir  Inieeal  side  of 
I  he  iiii'sial  rout  ut'  ;i  Iduit  lirst  molar,  of  possibly  tlivee  In  livf  years  staiKiinj;. 
I'aticiit  tliirty  ti\c  ycais  old.  Tisane  ciil  away  liy  l')r.  \rlliiir  D.  IMacii,  Aiiy;ust  :i, 
lit)  I.  Till'  ciiitliclial  coMTiii;;'  is  slinw  ii  al  the  to|i  (if  llic  illiist  la  I  ioii.  the  low.T  jiart 
heiii^  toward  the  root.  I'.niidlcs  of  (iliers  air  seen,  with  iiiiicli  idiiiid  crll  inlilt  rat  ioii. 
Specimen   pivjiarrd   liy    Dr.    11.    .\.    Totts.      1  Miot  oiiiicro^i  a  pii    \>\     \h-.    l\    1"..    \oyos. 


^Hi'*; 


^^^r;.. 


>.^> 
»"  *,^\i  'i^>. 


*-  '=C*^J 


I''h;,    1^41^ 


Fig.  242.  Section  through  soft  tissue  ovorlyiiig  ii  pocket  on  the  buccal  side  of 
tlie  root  of  a  lower  first  i)icusiii(l,  evidently  of  long  standing.  Patient  tifty-five  years 
old.  Tissue  cut  away  liy  J)r.  Arthur  D.  Black,  November  Hi,  1914.  Although  some 
bundle-like  arrangement  of  fiber.s  may  be  made  out,  this  would  hardly  be  recognized 
as  having  once  been  peridental  membrane.  Specimen  prejiared  by  Dr.  H.  A.  Potts. 
Photomicrograph  by  Dr.  F.  B.  Noyes. 


chronic  suppurative  pericementitis.  161 

Causes  Leading  to  Formation  of  Pus  Pockets. 

A  Gingivitis  always  precedes.  Some  form  of  gingivitis  always 
precedes  the  formation  of  a  pus  pocket.  Deposits  of  serumal 
calculus  in  the  subgingival  space,  or  the  various  forms  of 
injuries  to  the  gingivae  which  have  been  mentioned,  are  the  most 
frequent  forerunners.  As  has  been  stated,  deposits  of  salivary 
calculus  usually  destroy  all  of  the  tissue  overlying  the  root  to 
a  depth  even  with  the  deposit,  and  pockets  alongside  the  root 
are  not  formed,  as  a  rule,  except  in  the  later  stages.  While 
superficial  suppuration  of  the  tissue  which  is  covered  over  by 
the  deposit  is  commonly  present,  it  is  only  in  a  limited  number 
of  cases  that  the  peridental  membrane  is  stripped  away  from 
the  cementum  in  advance  of  the  destruction  of  the  overlying 
tissue.  Deposits  of  salivary  calculus  should  not,  therefore,  be 
considered  as  a  cause  of  suppurative  pericementitis  in  other  | 
than  exceptional  cases. 

Deposits  of  serumal  calculus  on  the  enamel.     Deposits  \ 
of  serumal  calculus  on  the  enamel  within  the  subgingival  space 
cause  most  of  the  pus  pockets  occurring  on  buccal,  labial  and 
lingual  surfaces.    As  has  been  explained,  the  presence  of  these 
deposits  causes  or  increases  the  inflammation  of  the  gingivaB 
and  suppuration  occurs.    Sooner  or  later  the  attachment  of  the  | 
peridental  membrane  to  the  cementum  becomes  involved  and  is   I 
cut  loose.    This  is  the  beginning  of  a  case  of  suppurative  peri- 
cementitis. 

Injuries  to  the  gingiva.  By  far  the  largest  nmnber  of 
cases  occur  as  a  result  of  injuries  to  the  gingivae,  and  of  these 
the  injuries  to  the  septal  tissue  by  the  impaction  of  food  between 
the  teeth  in  any  of  the  many  conditions  cited,  are  both  the  most 
frequent  and  the  most  serious.  In  these  cases,  the  irritation 
caused  by  the  presence  of  the  impacted  food,  and  the  poisoning 
of  the  tissue  as  a  result  of  the  decomposition  of  the  food,  both 
play  a  part  in  establishing  and  maintaining  the  inflammation. 
In  some  cases  the  impaction  may  of  itself  result  in  the  beginning 
detachment  of  the  peridental  membrane  at  the  gingival  lino. 
More  frequently  a  suppuration  occurring  in  the  inflamed  tissue 
causes  the  first  detachment.  Both  may  be  more  or  less  respon- 
sible. 

Systemic  conditions.  Many  men  have  believed  that  sj's- 
temic  conditions  have  been  the  principal  factors  in  causing  the 
diseases  of  the  membranes  about  the  teetli.  I  have  nl ready 
referred  to  this  in  the  brief  historical  sketch  of  the  development 


162  SPECIAL   DENTAL   PATHOLOGY. 

of  our  knowledge  of  the  diseases  of  these  tissues.  It  must  be 
recognized  that  the  general  physical  condition  of  an  individual 
will  have  its  etfect  on  the  progress  of  such  a  lesion  in  the  mouth, 
yet  I  can  not  to-day,  from  a  review  of  the  literature,  or  from  my 
own  investigations,  believe  that  more  than  a  very  limited  num- 
ber of  cases  originate  from  systemic  causes,  I  have  gradually 
come  more  and  more  to  the  belief  that  careful  obsen^ation  and 
records  during  the  early  stages  will  establish  the  fact  that  there 
is  a  local  exciting  cause  in  nearly  every  case. 

Specific  infections.  The  theory  that  some  particular 
organism  is  directly  responsible  for  this  chronic  suppurative 
condition  is  a  very  natural  one,  and  such  an  organism  has  been 
searched  for  almost  continuously  for  many  years.  This  has 
already  been  mentioned.  On  the  basis  of  our  present  knowledge, 
it  would  seem  that  the  organisms  concerned  in  the  destructive 
detaclmient  of  the  membrane  are  factors  by  which  the  tissue 
becomes  involved  secondarily  to  some  of  the  irritations  men- 
tioned. 

Endameba  buccalis.  During  the  past  year  a  number  of 
interesting  articles*  have  appeared  relating  the  finding  of 
endamebas  in  these  pus  pockets  about  the  teeth.  The  first  of 
these  was  by  Dr.  M.  T.  Barrett,  of  Philadelphia.  There  seems 
to  be  no  question  but  that  these  organisms  are  present  in  prac- 
tically all  pockets  about  the  teeth.  It  also  seems  that  they  are 
present  secondary  to  some  other  primary  exciting  cause  of  the 
gingivitis.  The  study  of  the  endamebas  and  their  full  relation 
to  this  disease  has  not  yet  progressed  sufficiently  to  justify  a 
full  discussion,  and  therefore  only  a  brief  statement  will  be 
given. 

Endameba  is  a  term  applied  to  parasitic  ameba.  The 
endameba  buccalis  is  found  in  the  depth  of  pus  pockets  about  the 
teeth.  Some  of  the  contents  of  the  pocket  may  be  diluted  with 
normal  salt  solution  and  microscopical  examination  will  reveal 

*  Barrett,  M.  T.:  The  Protozoa  of  the  Mouth  in  Relation  to  Pyorrhea  Alveolaris, 
Dental  Cosmos,  Vol.  56,  1914,  p.  948. 

Smith,  A.  J.,  Middlcton,  W.  S.,  and  Barrett,  M.  T.:  The  Tonsils  as  a  Habitat 
of  Oral  Endamebas,  .Tournal  American  Medical  Association,  Nov.  14,  1914,  p.   1746. 

Bass,  C.  C,  and  Johns,  F.  M. :  New  Orleans  Med.  and  Surg.  Jour.,  Vol.  67,  1914, 
p.  4.56. 

Barrett,  M.  T. :  Clinical  Report  on  Amoebic  Pyorrhea,  Dental  Cosmos,  Vol.  56, 
1914,  p.  1.345. 

Evans,  .T.  S.,  and  Middleton,  W.  S. :  Endamebic  Pyorrhea  and  Its  Complications, 
Journal  American  Med.  Assn.,  Jan.  30,  1915,  p.  422. 

Bass,  C.  C,  and  .Tohns,  F.  M. :  Pyorrhea  Dentalis  and  Alveolaris,  Journal  Ameri- 
can Medical  Association,  Feb.  13,  1915,  p.  553. 

Endabenias  in  Pus  Pockets  About  the  Teeth.  Editorial,  Journal  of  the  American 
Medical  Association,  Feb.  13,  1913,  p.  593. 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  163 

the  presence  of  the  motile  endamebas.  The  following  descrip- 
tion is  given  by  Bass  and  Johns  in  the  February  13,  1915,  issue 
of  the  Journal  of  the  American  Medical  Association. 

"They  vary  considerably  in  size  and  shape  but  with  very 
little  experience  they  are  easily  recognized.  The  clear  ectosaro 
may  project  one  or  more  pseudopodia,  draw  them  back,  project 
others  in  another  direction,  or  the  whole  parasite  may  flow 
slowly  in  one  direction  or  another,  A  pseudopod  of  ectosarc 
seems  to  always  precede  endosarc  when  it  moves.  Granules 
resembling  portions  of  red  blood  cells  in  the  endosarc  help  to 
give  to  the  parasite  an  appearance  similar  to  that  of  E.  histo- 
lytica. The  largest  of  the  buecalis  are  about  the  size  of  the 
histolytica.  Stained  specimens  are  perhaps  more  easily  diag- 
nosed, especiall}^  by  those  not  very  familiar  with  endamebas. 
They  may  be  stained  by  any  one  of  several  different  methods, 
but  the  following  is  good  enough  for  all  ordinary  purposes: 
(1)  Spread  pus  on  slide;  (2)  fix  with  heat;  (3)  pour  on  carbol 
fuchsin;  (4)  wash  off  at  once;  (5)  stain  with  Loeffler's  methy- 
lene blue  one-fourth  to  one-half  minute;  (6)  wash,  dry  and 
examine  with  oil-immersion  lens.  With  this  stain  the  endo  and 
ectoplasm  are  well  differentiated  and  the  parasite  can  be  differ- 
entiated from  the  much  more  numerous  pus,  epithelial,  and  other 
cells  present.  Their  size  varies  from  about  three  times  the 
diameter  of  a  pus  cell  down  to  smaller  than  pus  cells.  The  large 
parasites  contain  in  their  endoplasm  one  or  more  large,  dense, 
staining  bodies  or  granules  which  appear  to  be  the  nuclei  of  pus 
cells.  There  is  usually  a  clear  zone  around  each  of  these,  and 
also  around  the  entire  parasite.  This  is  apparently  due  to 
shrinkage  in  drying  or  fixing  the  preparation.  When  s,tained 
with  this  stain  the  endamebas  are  darker  stained  than  the  pus 
and  other  cells  in  the  preparation.  In  a  preparation  containing 
many  parasites  they  can  be  seen  with  the  low  power  lens  stud- 
ding the  field  as  blue  dots." 

To  examine  for  these  organisms  without  staining  a  very 
fine  pointed  pipette  should  be  introduced  deeply  into  the  pus 
pocket  and  a  small  quantity  of  its  contents  drawn  into  the 
pipette.  In  order  to  dilute  it,  three  drops  of  steril  salt  solution 
should  be  put  into  a  test-tube  of  one-fourth  inch  diaineter;  then 
the  point  of  the  pipette  should  ])e  introduced  into  the  salt  solution 
and  its  contents  forced  out  of  the  pipette  into  the  salt  solution. 
A  glass  slide  with  a  depression  should  be  used  to  receive  the 
specimen  to  be  examined.  Around  the  de]iression  a  smear  of 
vaseline  should  be  i)laced  and  a  cover-glass  dropped  over  it. 


164  SPECIAL   DENTAL   PATHOLOGY. 

The  slide  may  then  be  placed  in  the  thermostatically  governed 
warmed  stage.  When  the  temperature  reaches  98°  the  amebas, 
if  present,  become  motile,  and  may  be  readily  distinguished 
from  the  other  organisms,  tissue  cells,  etc.  The  use  of  an  enda- 
mebacide  in  treatment  is  mentioned  on  page  199. 

Symptoms  and  Tissue  Changes. 

The  symptoms  of  suppurative  pericementitis  are  those  of 
the  preceding  gingivitis  plus  those  which  come  with  the  gradual 
development  of  the  pus  pocket.  A  careful  study  of  a  large  num- 
ber of  cases  presenting  these  pockets  beside  the  roots  of  teeth 
shows  this  condition  very  unique  in  character.  No  other  condi- 
tion like  it  can  occur  in  the  human  body  because  there  is  no 
other  such  relation  of  tissues  as  exists  here.  If  periosteum  is 
stripped  from  bone,  a  portion  of  the  bone  dies,  and  is  separated 
and  exfoliated  by  the  action  of  the  deeper  cells  within  the  bone ; 
when  the  cells  which  build  the  cementum  are  stripped  from  it, 
it  also  becomes  a  dead  tissue,  but  there  is  no  provision  for  its 
exfoliation,  and  it  therefore  remains  as  a  constant  irritant  to 
the  overlying  tissue.  This  has  been  explained  in  the  historical 
summary  of  the  planting  of  teeth,  including  replanting,  trans- 
planting and  implanting.  In  some  of  these  cases,  attachment 
of  the  soft  tissues  to  the  cementum  occurs,  but  this  attachment 
has  been  shown  to  be  physiologically  unstable,  as  manifested 
by  the  absorption  of  the  planted  root  and  the  falling  away  of 
the  tooth. 

IjOcations  of  pus  pockets. 

The  pus  pocket  is  most  frequent  as  an  original  or  beginning 
disease  in  the  biscuspid  and  molar  region  —  the  region  of  the 
mouth  in  which  the  heaviest  work  of  mastication  occurs.  By 
far  the  greater  number  of  cases  occur  from  injury  of  the  septal 
tissues  by  the  impaction  of  food  between  some  particular  teeth 
in  eating.  For  some  reason  the  contact  points  between  certain 
teeth  begin  to  allow  food,  which  is  a  bit  tough  and  string;^^  to 
pass  and  lodge  between  the  two  teeth,  causing  an  inflammation 
of  the  septal  tissue.  In  a  similar  way,  a  more  limited  number  of 
cases  occur  in  the  incisor  region.  Cases  which  occur  as  a  result 
of  the  deposit  of  serumal  calculus  on  the  enamel  in  the  sub- 
gingival space,  or  of  any  of  the  injuries  to  the  gingivae  which 
have  been  mentioned,  may  be  observed  about  teeth  in  any  posi- 
tion in  the  mouth.  Deposits  of  serumal  calculus  in  the  sub- 
gingival space  occur  most  frequently  on  the  front  teeth. 


chronic  suppurative  pericementitis.  165 

Changes  in  the  tissues. 

The  steps  in  the  destruction  of  the  investing  tissues  in  this 
disease  are:  (1)  Gingivitis  which  affords  the  opportunity  for 
infection,  (2)  Suj^purative  inflammation  which  detaches  the 
peridental  membrane  from  the  cementum.  (3)  Destruction  of 
the  cementoblasts,  gradual  disappearance  of  the  fibers  of  the 
peridental  membrane  of  the  detached  area.  (4)  Absorption  of 
the  area  of  the  alveolar  process  to  which  the  detached  fibers 
were  connected.  (5)  A  granular  condition  of  the  inner  sur- 
face of  the  soft  tissues  covering  the  pus  pocket.  (6)  Absorption 
by  the  denuded  cementum  of  the  products  of  the  suppurative 
and  putrefactive  processes. 

These  changes  may  be  recognized  by  a  close  observation 
of  progressive  cases,  by  the  use  of  very  thin  flat  explorers  to 
determine  the  depth  of  pockets,  by  microscopical  examination 
of  sections  of  the  tissues,  and  by  radiographs  taken  at  a  favor- 
able angle  across  a  root  which  has  a  diseased  membrane. 

Appearance  of  the  gingiva.  The  condition  of  the  gingivjB 
and  overlying  soft  tissue  varies  remarkably.  In  some  cases  in 
which  the  pus  pockets  are  very  deep,  the  gingivae  look  well. 
Sometimes  they  are  only  a  little  shortened.  They  present  no 
distinct  redness  except  in  the  paroxysms  of  acute  inflammation. 
In  other  cases  the  soft  tissues  are  almost  constantly  inflamed 
and  red.  The  crest  of  the  gingivae  overlying  pus  pockets  often 
has  a  peculiar  appearance  which  is  more  or  less  characteristic 
of  the  condition.  The  edge  of  the  gingivae  may  be  rather 
smoothly  rounded  away  from  the  surface  of  the  enamel,  and 
will  have  an  unusually  smooth,  glossy  appearance.  This  will 
include  only  the  margin  and  possibly  one  or  two  millimeters  of 
the  outer  surface.  This  strip  may  be  very  slightly  bluish  in 
color,  in  comparison  with  the  adjacent  tissue. 

The  following  case  is  one  in  which  I  overlooked  a  deep 
pocket.  A  physician,  with  whom  I  had  been  intimately  asso- 
ciated for  a  number  of  years,  came  in  for  examination,  com- 
plaining of  a  lower  first  molar.  His  mouth  appeared  to  be  in 
excellent  condition,  except  for  a  cavity  in  the  mesial  surface  of 
the  tooth  of  which  he  complained.  I  at  once  prepared  the  cavity 
and  placed  a  gold  filling.  The  next  day  he  returned  complain- 
ing that  the  tooth  was  veiy  sore  and  extremely  ])ainful  to  the 
touch  of  the  upper  tooth.  I  then  discovered  what  I  had  over- 
looked before,  that  the  septal  tissue  was  detached  from  the  distal 
side  of  the  distal   root  of  this  tooth.     Taking  a  subgingival 

18 


166  SPECIAL   DENTAL   PATHOLOGY. 

explorer,  I  x>assed  it  alongside  the  distal  surface  of  the. first 
molar  and  it  entered  a  pocket  which  extended  almost  to  the 
apex  of  the  root.  So  much  tissue  had  been  destroyed  that  it 
was  necessary  to  extract  the  tooth.  Had  I  been  more  careful 
in  my  examination  on  the  previous  day,  I  could  have  saved  both 
the  patient  and  myself  the  trouble  of  the  gold-filling  operation. 

Infection  and  detachment.  Subsequent  to  such  injuries 
as  have  been  mentioned,  a  pyogenic  infection  may  occur  and  a 
little  pus  may  be  formed.  At  first  this  may  be  only  the  microbic 
decomposition  of  some  plastic  exudate  thrown  out  by  the  inflam- 
matory movement,  and  no  actual  tissue  destruction  may  occur. 
The  condition  is  that  of  constant  reinfection,  for  there  is  no 
time  that  the  saliva  is  free  from  micro-organisms  which  may 
produce  pus,  when  the  formation  of  plastic  exudates  gives  them 
the  opportunity.  There  may  be  pus  formation  in  the  tissue  of 
the  gingivae  apart  from  the  attachment  of  the  peridental  mem- 
brane. Such  an  infection  will  heal  at  the  first  opportunity, 
which  usually  comes  speedily,  as  would  a  slight  pus  formation 
in  any  other  of  the  soft  tissues. 

At  the  next  irritation  and  slight  pus  formation,  the  attach- 
ment of  the  peridental  membrane  at  the  gingival  line  may  be 
involved,  by  cutting  away  some  portion  of  the  fibers  from  the 
cementum.  This  may  be  repeated  and,  little  by  little,  fibers 
may  be  destroyed;  or  as  a  result  of  a  more  violent  infection,  a 
larger  area  of  fibers  may  be  detached. 

According  to  the  view  that  we  can  not  obtain  an  attacli- 
ment  to  the  cementum  except  in  aseptic  conditions,  there  is  no 
chance  whatever  for  a  reattachment.  The  suppuration  may 
cease  for  a  time  and  the  soft  tissue  heal,  except  that  this  attach- 
ment to  the  cementiun  is  not  renewed.  This  occurs  time  after 
time,  and  the  destruction  goes  deeper  and  deeper  with  each 
renewal  of  the  inflammatory  movement. 

Pus  may  or  may  not  be  present  at  the  time  of  examination. 
In  many  cases,  on  pressure  upon  the  lateral  sides  of  the  arch 
with  the  fingers,  pus  wells  up  from  under  the  margin  of  the 
gingiva;  or  about  the  tissue  which  remains.  This  pus  is  often 
undergoing  putrefactive  decomposition  and  is  very  foul  smel- 
ling. In  advanced  cases,  numerous  pockets  are  constantly  exud- 
ing pus  and  the  products  of  decomposition,  making  the  patient's 
mouth  a  veritable  cesspool,  and  we  can  but  marvel  at  nature's 
wonderful  resistance  which  protects  and  prolongs  the  lives  of 
so  many  persons  whose  mouths  are  in  this  condition.  Every 
type  of  case  will  be  seen,  between  this  and  the  mildest  appearing 


CHRONIC    SUPPURATIVE   PERICEMENTITIS.  167 

cases  in  which  no  trace  of  pus  may  be  found,  although  the  sub- 
gingival explorer  may  reveal  deep  pockets. 

Pockets  progress  most  toivard  apex  of  root.  The  pockets 
gradually  become  deeper,  often  following  one  side  of  a  root,  or 
even  a  narrow  space,  but  always  progressing  toward  the  apex 
of  the  root.  In  some  instances  a  wide  destruction  of  the  peri- 
dental membrane  over  the  side  of  a  root  may  occur  during  a 
single  inflammatory  movement.  But  whether  the  destruction 
be  rapid  or  slow,  there  is  a  constant  tendency  to  destroy,  pro- 
gressively, toward  the  apex  of  the  root,  rather  than  to  spread 
around  the  root.  This  fact  has  been  fully  established  by  a  care- 
ful examination  of  cases ;  many  of  them  at  numerous  intervals 
during  their  progress. 

Some  questions  as  to  the  exact  pathological  conditions  and 
tendencies  remain  for  future  consideration.  From  all  that  I 
can  now  see,  the  peridental  membrane  itself  is  followed  in 
preference  to  other  tissues  in  this  destructive  process.  This 
process  may  go  on  even  to  the  apex  of  the  root  of  a  tooth,  while 
the  peridental  membrane  may  remain  healthful  over  other  por- 
tions of  the  root.  The  remaining  attached  tissue  may,  and  often 
does,  sustain  the  tooth  so  completely  that  it  performs  the  usual 
service  in  mastication.  Finally  a  time  comes  when  a  tendency 
to  spread  around  the  root  of  the  tooth  occurs.  This  is  usually 
marked  by  an  increase  in  the  amount  of  pus  discharged  and  a 
rapid  loosening  of  the  tooth. 

There  is  one  point  in  the  patholog^^  of  the  peridental  mem- 
brane that  will  be  noticed  as  differing  very  materially  when 
comparisons  are  made  between  disease  beginning  at  the  apex 
of  the  root  and  disease  beginning  in  the  gingivsR.  There  is  no 
such  disposition  for  the  destructive  effect  in  alveolar  abscess 
to  follow  the  peridental  membrane  toward  the  gingivae,  as  in 
disease  beginning  in  gingiva?  to  follow  the  peridental  meml)rane 
toward  the  apex  of  the  root.  This  marks  the  two  affections  as 
differing  from  each  other,  although  both  are  suppurative.  Why 
this  difference  I  have  found  no  satisfactory  explanation. 

In  acute  alveolar  abscess,  as  ordinarily  seen,  there  is  no 
destruction  or  detachment  of  fibers  of  the  peridental  membrane 
from  the  end  of  the  root.  This  occurs  only  in  chronic  cases. 
The  destructive  process  is  directed  toward  the  bone  surrounding 
the  end  of  the  root,  and  very  soon  the  abscess  is  mostly  within 
the  cancellous  portion  of  the  bone.  Tt  does  not  follow  the  peri- 
dental membrane. 

Failures  of  reattachment.    Failures  of  reattachment  of  the 


168  SPECIAL   DENTAL   PATHOLOGY. 

soft  tissues  to  the  eementiim,  which  luis  l)een  denuded,  is  a,  con- 
stant principal  factor.  I  have  carefully  nursed  comparatively 
small  breaks  in  the  attachment  of  the  membrane  upon  the  buccal 
or  labial  sides  of  the  teeth,  which  I  could  plainly  see,  and  have 
brought  them  back  to  a  condition  of  apparent  health.  But  this 
has  been  at  the  sacrifice  of  the  length  of  the  gingivse.  If  I  did 
not  cut  this  away  to  uncover  the  pocket,  it  would  shrink  down 
after  healing  was  accomplished,  leaving  a  notch  in  the  line  of 
the  crest  of  the  free  gingivae.  The  healing  was  not  from 
reattachment  to  the  cementmn,  but  by  the  tissues  accepting  a 
new  line  of  gingival  attachment.  Even  then,  a  depression  is 
left  which  catches  debris  and  is  difficult  to  clean  perfectly,  and 
thus  continues  as  a  menace  to  the  health  of  the  parts.  Such 
cases  show  very  plainly,  the  difficulties  accruing  as  a  result  of 
the  general  failure  of  reattachment. 

Cases  tend  to  progress.  When  suppuration  has,  as  a  result 
of  inflammation  of  the  septal  tissues,  destroyed  the  attachment 
of  some  part  of  the  peridental  membrane  to  the  ceraentum 
between  two  bicuspids,  between  a  bicuspid  and  a  molar,  or 
between  two  molars,  there  is  not  much  chance  that  it  will 
cease.  The  infection  is  shut  in  completely  by  the  two  teeth, 
by  the  covering  of  the  remaining  septal  tissue  and  by  the  lodg- 
ment of  food  debris.  Fresh  infection  is  constant  under  condi- 
tions favorable  for  its  action.  For  these  reasons  the  suppura- 
tion generally  continues  and  goes  deeper  into  the  attachment 
of  the  membrane  to  the  cementum. 

Destruction  of  cementoblasts,  fibers  of  peridental  mem- 
brane, AND  the  alveolar  PROCESS.  Subscquent  to  detachment 
from  the  cementum,  the  changes  which  take  place  in  the  investing 
tissues  are  of  first  importance  in  the  consideration  of  these  cases. 
These  were  fully  presented  in  the  discussion  of  the  physiological 
functions  of  the  various  elements  contained  within  the  peridental 
membrane.  It  was  pointed  out  that  the  fibers  of  the  peridental 
membrane  are  cut  off  close  to  the  cementum,  that  these  fibers 
are  subsequently  absorbed  and  later  the  portion  of  the  bone  of 
the  alveolar  process  to  which  they  were  attached  also  disappears 
by  absorption.  The  cementoblasts  are  also  destroyed  over  the 
area  of  detachment.  There  remains  a  tissue  which,  having  lost 
those  special  elements  which  characterize  the  peridental  mem- 
brane, has  also  lost  the  functions  performed  by  those  elements. 
The  denuded  cementum  has  become  saturated  with  the  elements 
of  suppuration  and  decomposition,  rendering  it  negatively 
chemotactic  to  those  cells  within  the  overlying  tissues  which 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  169 

might  otherwise  attach  themselves  to  it  in  the  manner  in  which 
attachment  may  occur  to  planted  teeth. 

The  disappearance  of  the  cementoblasts  and  principal  fibers 
of  the  peridental  membrane  is  shown  by  microscopical  exam- 
ination of  sections  of  the  tissue.  Such  sections  show  the  tissue 
to  be  more  or  less  filled  with  inflammatory  elements  which  have 
replaced  the  bundles  of  fibers  and  the  cementoblasts.  Depend- 
ing upon  the  extent  and  duration  of  the  pocket,  there  may 
remain  scattering  long  fibers  or  none  at  all. 

The  series  of  illustrations,  Figures  236  to  242,  are  presented 
for  the  particular  purpose  of  showing  the  changes  which  occur 
in  the  tissues.  Figures  236  and  237  are  of  normal  peridental 
membrane,  the  fibers  of  which,  together  with  the  cementum  and 
alveolar  process,  are  beautifully  shown.  These  may  be  com- 
pared with  the  other  illustrations  of  the  series,  in  which  the 
extent  to  which  the  special  elements  have  been  lost  can  be 
observed.  For  example,  Figures  239  and  240  are  from  tissue 
cut  from  a  pocket,  apparently  of  many  years'  standing,  and 
there  is  nothing  left  in  this  tissue  by  which  it  could  be  identified 
as  having  ever  been  attached  to  the  root  of  a  tooth.  The  spe- 
cialized elements  have  all  disappeared.  Figures  241  and  242 
show  some  fibers  remaining,  but  much  infiltration  of  inflamma- 
tory elements.  The  three  sections.  Figures  239,  241  and  242, 
were  all  cut  from  positions  in  which  there  would  have  been  bone 
of  the  alveolar  process  under  normal  conditions,  but  it  is  entirely 
gone.  It  would  seem  that  these  illustrations  alone  should  be 
sufficient  to  establish  the  fact  that  a  normal  reattachment  of  the 
tissue  to  the  root  is  impossible. 

Absorption  of  alveolar  process  best  shoivn  by  radiographs. 
The  absorption  of  the  alveolar  process  is  best  shown  by  radio- 
graphs, although  in  cases  in  which  considerable  progress  has 
been  made,  the  absence  of  the  bone  may  be  easily  noted  by 
digital  examination.  Oftentimes  a  rather  sharp  edge  of  the 
remaining  alveolar  process  may  be  felt  and  the  contour  of  the 
roots  may  be  made  out  where  they  are  covered  only  by  soft 
tissue.  The  radiograph  has,  however,  demonstrated  very  clearly 
that  the  absorption  of  the  alveolar  process  begins  much  earlier 
and  is  often  more  general  and  more  extensive  than  had  formerly 
been  recognized.  It  has  become  my  rule  in  the  study  of  these 
cases,  as  a  basis  for  prognosis  and  treatment,  to  have  radio- 
graphs made  of  the  entire  alveolar  process,  as  these  show  in  a 
very  definite  way,  the  extent  to  which  the  tissues  have  become 
Involved.     A  series  of  such  radiograplis,  taken  at  stated  inter- 


170  SPECIAL   DENTAL   PATHOLOGY. 

vals  for  individual  cases,  furnish  an  accurate  record  of  the 
progress  which  the  disease  has  made. 

Radiographs  may  be  taken  of  pockets  on  a  proximal  sur- 
face by  holding  the  film  close  against  the  alveolar  process  on  the 
lingual  side,  and  so  directing  the  rays  that  they  will  pass 
through  the  interproximal  space  in  the  bucco-ling-ual  direction. 
The  absoi'ption  begins  on  the  inner  surface  of  the  alveolar  pro- 
cess, and  as  tlie  case  progresses  the  area  of  absorption  l)eeomes 
fimnel-shaped,  dipping  at  an  angle  toward  the  apex  of  the  root. 
Also  a  certain  amount  of  the  peridental  membrane  farther 
apically  is  shown  to  be  involved  in  suppuration,  appearing  as 
a  fine  line  in  the  radiograph.  This  shows  that  the  progress  of 
the  suppuration  is  practically  confined  to  the  peridental  mem- 
brane. The  absorption  occurs  secondarily,  in  part  as  a  result 
of  the  detachment  of  the  peridental  membrane  from  the 
cementum  and  in  part  directly  by  the  suppurative  process.  I  am 
inclined  to  the  belief  that  the  detachment  of  the  peridental  mem- 
brane from  the  cementum  is  the  principal  factor  in  causing  the 
loss  of  the  bone. 

^fany  radiographs,  made  by  the  most  experienced  radiog- 
raphers, show  the  extent  to  which  the  bone  has  been  destroyed 
on  the  labial,  buccal  or  lingual  surfaces,  although  it  can  not  be 
determined  from  the  examination  of  the  radiograph  alone 
whether  the  bone  which  has  been  lost  is  on  the  buccal  or  the 
lingual  side  of  a  root.  This  must  be  done  by  an  examination  of 
the  tissues.  If  bone  has  been  destroyed  on  both  the  buccal  and 
lingual  surfaces,  this  will  generally  be  shown  by  the  radiograph. 

The  accompanying  illustrations,  made  from  radiographs, 
present  every  stage  of  progress  of  absorption  of  the  alveolar 
process.  Particular  attention  is  called  to  the  panoramic  repro- 
ductions of  radiographs  of  entire  dentures  which  have  been  pre- 
pared by  Dr.  Arthur  D.  Black.  These  give  a  wonderfully  clear 
idea  of  the  extensive  destruction  of  bone  which  occurs  in 
advanced  cases.  Figures  232  and  233  are  of  a  normal  healthy 
mouth  of  a  young  man  who  has  been  free  from  diseases  of  the 
teeth  and  investing  tissues.  The  position  of  the  crests  of  the 
septi  of  the  alveolar  process  will  serve  as  a  basis  for  judging  the 
extent  to  which  the  bone  has  been  destroyed  in  cases  represented 
by  the  numerous  other  illustrations. 

Figures  234  and  235  are  panoramic  reproductions  from  a 
mouth  in  which  there  were  but  two  normal  septi  —  between  the 
lower  cuspid  and  first  bicuspid  on  one  side,  and  between  the 
lower  bicuspids  on  the  other.    Figure  261  is  another  panoramic 


Fig.  243. 


Fig.  244. 


Fig.  245. 


Figs.  243,  244,  245.  These  three  reproductions  of  radiofjraphs  are  from  the 
mouth  of  the  same  patient,  who  first  consulted  a  rhinolofjist  because  of  a  suppuration 
of  the  maxillary  sinus.  In  this  case  the  gums  and  fjingivie  nuide  a  fine  appearance, 
notwithstandinfj  the  fact  that  several  pockets  were  very  deep.  The  separation  of 
the  teeth  mav  be  iidliccd   in    Fiifiircs  2-14   and  245. 


*18 


Fifi.  24(). 


Fig.  247. 


^la  I  '    itx 


Fig.  248. 


Fig.  249. 


Figs  246  247  248  249  These  four  radiographic  reproductions  are  from  the 
mouth  of  the  'same'  patient.  In  this  case  the  gingiva>  were  much  inflamed  and  pus 
could  be  pressed  out  about  many  of  the  teeth,  although  most  of  the  pockets  were  not 
deep. 


Fig.  250. 


Fig.  2.51. 


Fig.  25- 


Fig.  250.  Tlie  iippor  front  toctli  :ui(l  rcinaiiiiiitj  alveolar  process,  man  forty-live 
years  old.  Pus  could  be  pressed  out  about  these  teeth,  partieularly  to  the  liiifrual. 
This  patient  had  suffered  from  several  attacks  of  arthritis. 

Figs.  251  and  252.  Eeproduction  of  radiographs  siiowing  the  funnel-shaped 
destruction  of  the  bone  of  the  alveolar  process.  The  radiograph  shown  in  Figure  252 
was  furnished  by  T)r.  Thomas  L.  Gilmer.  Small  wires  had  been  carried  into  the 
canals  as  far  as  possible  just  before  the  radiograpii  was  made. 


Fig.  253. 


Fig.  254. 


Fig.  255. 


Fig.  256. 


Fig.  257. 


Fig.  258. 


Figs.  253  to  258.  Photographs  of  toeth  with  heavy  deposits  of  serumal  calculus. 
The  membrane  had  been  detached  quite  to  the  end  of  the  root  in  Figures  253,  255 
and  257.  Figure  254  is  a  third  inoljir  uliich  was  only  partially  rrupt(><l,  and  the 
deposit  covers  almost  the  entire  crown.  Figures  25G  and  258  are  of  cases  in  which 
the  pockets  were  not  very  deep,  luit  the  d('|)osits  were  heavy.  All  of  the  specimens 
are  from  Northwestern  Universitv  Dental  Museum. 


Fig    259. 


Fig.  259.  Ground  section  of  a  nodule  of  serunial  calculus  on  the  cementum.  A 
little  of  the  enamel  is  shown  in  the  upper  right  corner  of  the  picture.  This  illustra- 
tion gives  a  good  idea  of  the  nodular  forms  generally  found  in  pus  pockets.  I  have 
often  called  this  pus  pocket  calculus. 


Fig.  26U. 


Fig.  261. 


Fig.  260.  Two  views  of  a  plaster  model  of  a  case  of  chronic  suppurative  peri- 
cementitis, showing  the  protrusion  of  the  upper  incisors,  also  the  movement  of  the 
teeth.  It  required  a  special  effort  for  this  patient  to  hide  the  teeth  with  her  lips. 
The  .separation  of  the  central  incisors  followed  the  complete  detachment  of  the  trans- 
septal  fibers. 

Fig.  261.  Panoramic  radiographic  view  of  the  upper  teeth  and  alveolar  process 
of  the  same  case  as  Figure  260.  This  is  about  as  great  a  destruction  of  the  bone 
as  can  occur  while  the  teeth  remain  in  the  mouth.  Many  nodules  of  senunal  calculus 
may  be  seen  on  the  roots.  This  patient,  a  woman  of  forty  years,  had  suffered  from 
a  mild  arthritis  of  many  joints  for  more  than  five  years. 


Fig.  262. 


Fig.  263. 


Fig.  262.  A  lateral  abscess  between  the  second  bicuspid  and  first  molar.  There 
was  a  deep  j  ocket  to  the  distal  of  the  bicuspid  root  and  flic  ])us  had  penetrated  the 
soft  tissue  instead  of  discharyiny-  ahinyside  the  tooth.  These  are  often  nustakcn 
for  tnie  alveolar  abscesses. 

Fig.  263.  Model  showing-  the  tissue  destroyed  by  a  septal  abscess,  practically 
the  same  as  the  case  mentioned  above,  except  that  tlie  septal  tissue  was  principally 
involved.     Many  of  these  abscesses  destroy  quite  !i  Httle  bone  of  the  alveolar  process. 


Fig.  2G4. 


Fig  264.  Reproduction  of  illustratiou  drawn  by  the  author  for  the  American 
System  of  Dentistry,  1886.  (Vol.  I,  Fig.  520.)  This  was  probably  the  first  illustra- 
tion made  of  a  pus  pocket.  The  dotted  lines  a.  a.  represent  the  outlines  of  the  roots 
of  the  teeth.  The  shaded  lines,  b,  b,  represent  the  extent  of  the  detachment  of  the 
peridental  membrane  and  destruction  of  the  alveolar  process. 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  171 

reproduction  of  the  process  of  an  upper  jaw  showing  about  as 
extensive  destruction  of  bone  as  can  occur  while  the  teeth  remain 
in  the  mouth.  Figure  289  is  a  similar  panoramic  view.  Many 
other  illustrations,  from  Figures  243  to  252,  also  Figures  287 
and  288,  show  the  destruction  of  the  alveolar  process.  Figures 
234,  235,  243,  244,  245,  251,  252,  261,  287  and  289  all  show  more 
or  less  of  the  funnel  forms  in  the  bone. 

Granular  condition  of  soft  tissue  covering  the  root. 
The  inner  surface  of  the  soft  tissue  covering  the  portion  of  the 
root  from  which  the  peridental  membrane  has  been  stripped  is 
in  a  constant  state  of  inflammation,  even  though  the  superficial 
appearance  of  the  tissue  may  be  good.  This  tissue  will  be 
slightly  or  much  inflamed  at  different  periods,  depending  upon 
the  infection  present  at  the  time  and  the  condition  of  the  root. 
The  root  may  be  smooth,  without  deposits,  or  there  may  be 
various  forms  of  deposit  from  the  flattest  scales  to  the  more 
irregular  nodules. 

Absorption  by  the  denuded  cementum  of  products  of  sup- 
puration AND  PUTREFACTION.  The  ccmcutum  is  so  porous  that, 
in  cases  in  which  an  infection  has  been  in  progress  for  a  time,  it 
will  become  saturated  with  the  products  of  suppuration.  The 
pockets  are  often  invaded  by  putrefactive  organisms  which 
cause  decomposition  of  material  within  the  pockets  and  the 
cementum  absorbs  this  also.  This  condition  contributes  to  both 
the  chronicity  of  the  infection  and  the  inflammation  of  the  over- 
lying soft  tissue. 

The  porosity  of  both  dentin  and  cementum  was  well  illus- 
trated in  a  case  which  came  under  my  observation  a  few  years 
ago.  An  upper  central  incisor  in  the  mouth  of  a  man  forty 
years  of  age,  was  under  treatment  on  account  of  the  death  of 
the  pulp.  The  pulp  had  remained  dead  in  the  tooth  for  several 
years,  causing  it  to  be  considerably  discolored.  After  the  treat- 
ment of  the  root  canal  had  been  completed  and  the  apex  of  the 
root  securely  sealed  with  gutta-percha,  it  was  determined  to 
make  an  attempt  to  bleach  the  tooth,  and  twenty-five  per  cent 
pyrozone  was  sealed  in  for  the  purpose.  There  was  no  injury 
or  inflammation  of  the  peridental  membrane.  The  pyrozone 
was  sealed  in  at  nine  o'clock  in  the  morning  and  by  six  o'clock 
the  same  evening  the  entire  peridental  membrane  of  the  tooth 
was  in  a  high  degree  of  inflammation  as  a  result  of  the  penetra- 
tion of  the  dentin  and  cementum  by  the  pyrozone.  The  slightest 
touch  upon  the  crown  of  the  tooth  caused  sharp  pain.  By  the 
next  dav  the  inflammation  had  subsided.     Tliis  ojiei-ation  was 


172  SPECIAL   DENTAL   PATHOLOGY. 

repeated,  with  similar  results  on  two  other  days  within  the  next 
two  weeks. 

Complaint  of  pain. 

The  complaint  of  pain  in  connection  with  these  eases  is 
very  variable.  The  wide  difference  in  the  sensitiveness  of  the 
septal  tissue  to  food  impactions  has  been  mentioned.  As  the 
depth  of  pockets  increases,  patients  are  more  likely  to  complain 
of  soreness  of  the  teeth  to  the  stress  of  mastication,  than  of 
pain.  Cases  may  progress  to  the  stage  where  many  teeth  are 
hopelessly  involved  without  the  least  pain;  on  the  other  hand, 
there  will  be  acute  pain  in  many  cases  during  a  period  of  acute 
inflammation.  Both  the  tenderness  to  touch  and  the  pain  are 
more  apt  to  be  complained  of  when  the  inflammation  has  involved 
the  deeper  tissues,  near  the  apex  of  the  root,  and  the  swelling 
has  caused  the  tooth  to  be  slightly  lifted  in  its  socket.  The 
opposing  teeth  strike  it  every  time  the  mouth  is  closed,  and  this 
materially  increases  the  inflammation,  often  causing  the  tooth 
to  become  extremely  painful  and  tender  to  touch.  If  the  tooth  is 
given  rest  for  a  few  days  by  some  plan  which  relieves  the  occlu- 
sion on  it,  the  inflammation  will  generally  subside,  and  the  tooth 
may  again  be  used  in  mastication  without  discomfort.  Some 
slight  injury  or  a  new  infection  may  cause  a  repetition  of  the 
acute  symptoms.  This  may  occur  again  and  again  until  finally 
in  desperation  the  patient  will  consent  to,  or  possibly  insist 
upon,  the  extraction  of  the  tooth. 

Deposits  op  serumal  calculus. 

Deposits  of  serumal  calculus  may  or  may  not  be  present 
within  the  pockets  on  the  cementum  from  which  the  peridental 
membrane  has  been  detached,  although  they  generally  are  pres- 
ent. The  deposit  necessarily  occurs  subsequent  to  the  detach- 
ment. The  calcific  elements  are  Ijrought  to  the  pocket  with  the 
serum  which  is  exuded  into  the  syjace  from  tlie  overlying  tissue 
as  a  result  of  the  inflammation,  in  the  same  manner  as  deposits 
are  laid  down  upon  the  enamel  of  the  sul)gingival  spaces.  The 
nature  of  the  deposit  is  the  same;  the  only  difference  is  in  the 
form. 

Deposit  often  nodular.  The  deposit  of  serumal  calculus 
occurring  in  the  subgingival  space  is,  as  has  been  mentioned, 
usually  in  the  form  of  a  flattened  scale,  due  to  the  pressure  of 
the  gingivae  against  the  deposit  while  it  is  soft.  Within  the 
depth  of  a  pocket,  alongside  the  root,  the  soft  tissue  is  not  so 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  173 

inclined  to  hug  the  root  closely,  and  accretions  to  an  original 
nidus  of  deposit  are  likely  to  be  gradually  built  on  and  around, 
forming  a  nodule.  Either  the  scale  or  nodular  form  may  be 
present,  although  the  deposit  within  the  pocket  is  generally  more 
or  less  uneven.  The  difference  in  the  form  of  the  deposit  in  the 
subgingival  space  and  in  the  pocket  is  so  marked  that  I  have 
frequently  used  the  term  pus  pocket  calculus  to  designate  the 
latter  form.  (See  Figures  253  to  258,  also  Figure  261,  and  the 
series  of  illustrations.  Figures  268  to  284.)  Figure  259  is  a 
microscopic  section  of  a  nodule  attached  to  the  cementum. 

Occurrence  of  deposits.  Cases  are  observed  in  which  there 
are  no  deposits  whatever  in  pockets  of  many  years'  standing. 
My  recent  studies  of  the  nature  of  the  deposit  of  calculus  leads 
to  the  belief  that  for  such  individuals  the  balance  between  the 
quantity  of  food  digested  and  the  elimination  is  such  that  no 
excess  of  calco-globulin  is  present  in  the  bodj'-  fluids  and  there- 
fore none  is  brought  to  these  pockets  with  the  serum  which  is 
constantly  poured  out  into  them.  With  this  view,  all  such  per- 
sons should  also  be  free  from  deposits  of  salivary  calculus, 
because  if  deposits  of  salivary  calculus  are  occurring  in  a  mouth 
in  which  there  are  pus  pockets,  we  should  expect  a  correspond- 
ing proportion  of  calco-globulin  in  the  serum  of  the  pockets. 
It  does  not  necessarily  follow,  however,  that  salivary  calculus 
will  be  present  in  mouths  in  which  serumal  deposits  are  present, 
as  the  care  of  the  mouth  may  be  sufficiently  good  to  prevent  the 
accumulation  of  deposits  of  salivary  calculus,  or  the  forms  of 
the  gingivae  may  be  such  that  no  deposits  occur,  even  though 
calco-globulin  is  present  in  the  saliva.  Careful  clinical  observa- 
tions agree  with  these  statements. 

Deposit  contributes  to  progress.  When  deposits  have 
occurred  within  these  })0ckets,  they  serve  as  an  additional  irritant 
to  the  overlying  soft  tissue,  and  tend  to  maintain  the  inflam- 
matory movement.  This  irritation  results  in  the  continued  out- 
pouring of  excessive  amounts  of  serum,  which  will  in  turn  bring 
additional  calco-globulin  in  the  proportion  that  it  is  present  in 
the  body  fluids.  The  tissue  is  in  such  condition  as  to  invite 
suppurative  infections,  and  these  occur  frequently  or  continue 
with  slight  or  no  interruption.  Thus  it  will  be  seen  that  whilp 
the  deposits  are  secondary  to  pocket  formation,  they  become  one 
of  the  factors  to  the  continued  progress  of  the  disease. 

As  mentioned  in  the  consideration  of  gingivitis  caused  by 
deposits  of  serumal  calculus,  these  deposits  on  the  enamel  may 
be  the  original  beginning  of  cases  of  suppurative  pericementitis. 


174  SPECIAL    DENTAL    TATHOLOGY. 

though  they  account  for  but  a  small  percentage.  The  first 
inflammation  of  the  gingivae  may  be  due  to  the  deposits  of 
serumal  calculus  on  the  enamel  in  the  subgingival  spaces.  This 
may  provide  a  focus  for  a  pj'ogenic  infection  which  destroys  a 
little  of  the  attachment  of  the  peridental  membrane  at  the  gin- 
gival line.  Deposits  then  in  turn  occur  on  the  denuded  cementum. 
Another  suppuration  occurs,  more  tissue  is  detached,  new 
deposits  occur,  and  so  the  case  progresses. 

Enlargement  of  cervical  glands. 

During  the  progress  of  this  disease  there  is  apt  to  be  swel- 
ling of  the  cervical  glands,  which  drain  the  infected  area  in  the 
mouth.  It  has  often  seemed  to  me  that  the  amount  of  swelling 
of  these  glands  was  out  of  proportion  to  the  inflammation  about 
the  teeth.  In  some  cases,  in  which  there  is  very  slight  inflam- 
mation about  the  teeth,  there  may  be  considerable  enlargement 
of  the  glands  of  the  neck,  while  in  others,  in  which  the  mouth 
infection  is  extensive,  none  of  the  cervical  glands  can  be  pal- 
pated. The  swelling  of  these  glands  should  be  looked  upon  as 
a  danger  signal,  as  it  often  indicates  the  beginning  of  a  general 
infection  which  may  do  great  damage  by  the  establishment  of 
foci  elsewhere  in  the  body.  AVe  must  not  conclude,  howevev, 
that  the  absence  of  enlarged  cervical  glands  indicates  that  there 
is  no  systemic  danger,  because  most  of  the  secondary  infections 
are  probably  hematogenous.  The  submaxillary  gland  does  not 
often  partake  in  such  inflammations,  but  it  must  be  differen- 
tiated from  the  cervical  glands. 

Palpation  of  submaxillary  and  cervical  lymphatic  glands. 
The  most  effective  method  of  ])alpating  the  submaxillary  gland 
is  to  place  a  finger  of  one  hand  in  the  mouth  and  pass  it  under 
the  tongue  to  the  lower  border  of  the  inferior  maxillary  bone, 
at  about  the  position  of  the  molar  teeth,  and  a  finger  of  the  other 
hand  on  the  skin  below  the  jaw,  grasping  the  gland  between  the 
two  fingers.  The  two  first  fingers  are  best  to  use  in  this  exam- 
ination, as  they  are  more  sensitive  to  touch  than  the  others.  The 
first  finger  of  the  right  hand  should  be  placed  inside  the  mouth 
in  palpating  the  patient's  right  submaxillary  gland,  while  the 
first  finger  of  the  left  hand  will  be  best  in  the  mouth  in  pal- 
pating the  patient's  left  submaxillary  gland.  Sometimes  the 
little  finger  may  be  used  instead  of  the  first  finger  inside  the 
mouth.  The  posterior  end  of  the  gland  can  usually  be  definitely 
made  out,  about  even  with  the  distal  surface  of  the  second  molar. 
The  anterior  end  is  not  so  easily  determined.     The  gland  is 


CHRONIC    SUPPURATIVE   PERICEMENTITIS.  175 

usually  about  the  diameter  of  a  finger,  but  varies  considerably. 
If  there  is  tendei-ness  or  much  enlargement  it  may  be  discovered 
by  such  an  examination. 

Under  normal  conditions,  the  cei-vical  lymphatics  can  not 
be  palpated.  When  enlarged,  they  may  be  felt  as  movable 
nodules  of  variable  size  from  that  of  a  pea  to  a  large  filbert.  The 
patient's  head  should  be  tipped  forward  to  relax  the  muscles  of 
the  neck,  which  will  make  it  easier  to  palpate  these  glands.  If 
enlarged,  they  will  usually  be  found  just  under  the  skin  of  the 
neck,  a  little  below  the  lower  border  of  the  inferior  maxillary 
bone  and  anterior  to  the  sterno-clido-mastoid  muscle. 

Excitation  of  salivary  glands. 

There  is  an  almost  continuous  excitation  of  the  salivary 
glands  of  persons  afflicted  with  this  disease.  I  have  often 
watched  them  carefully  while  sitting  at  rest  in  my  chair,  or  in 
my  reception-room,  and  counted  the  acts  of  deglutition.  Often 
this  will  occur  three  to  five  times  per  minute.  When  questioned 
about  drooling  of  saliva  at  night,  many  have  told  me  that  it  was 
necessary  to  use  a  napkin  to  protect  the  pillow  from  this  flow. 
Those  who  sleep  lying  on  the  back,  swallow  this  material  uncon- 
sciously during  their  sleep. 

Movements  of  the  teeth  as  a  result  of  pocket  formation. 

One  of  the  very  important  items  in  the  study  of  the  path- 
ology of  these  cases  is  the  movement  of  the  teeth  which  occurs 
as  a  result  of  the  swelling  and  the  disturbance  of  the  balance  of 
pull  of  the  various  groups  of  fibers  of  the  peridental  membrane. 
In  order  to  understand  these  movements,  there  are  several  prin- 
ciples which  must  be  considered. 

It  is  important  that  the  general  structure  of  the  gingival 
tissues  and  the  influence  of  the  different  groups  of  fibers  which 
have  been  described,  be  held  strictly  in  mind.  The  fact  that 
these  fibers  pull  one  group  against  another  in  holding  the  teeth 
in  the  line  of  the  arch,  and  that  in  normal  conditions  these  pnll'^ 
are  accurately  balanced,  is  an  important  matter,  for  in  this  field 
of  pathology  much  havoc  results  from  the  disturbance  of  the 
balance  of  these  pulls. 

In  this  it  is  a  general  principle  that  wherever  the  fibers  of 
the  peridental  membrane  are  being  destroyed  along  one  side  of 
the  root  of  a  tooth,  so  that  their  normal  pull  upon  the  tooth  is 
broken  or  much  weakened,  the  pull  of  the  fibers  upon  the  well 
side  will  draw  the  tooth  away  from  the  diseased  side,  or  tend  to 


176  SPECIAL    DENTAL    PATHOLOGY. 

do  SO.  This  is  true  wherever  such  a  condition  occurs  and  it  will 
be  effective  unless  there  is  some  counteracting  force  to  prevent 
such  a  movement.  Sometimes  deeply  interlocking  cusps  with 
the  teeth  of  the  opposing  arch  will  prevent  such  a  movement,  and 
many  other  conditions  may  prove  temporarily  sufficient,  but  in 
the  long  run  all  of  these  tend  to  give  way. 

In  tliese  cases  there  seems  to  l)e  a  weakening  of  the  ])iill  of 
the  fibers  in  excess  of  the  actual  destruction  of  tissue.  We  know 
this  most  certainly  from  the  cessation  of  the  normal  pull  of  the 
fibers  during  an  inflammation  which  does  not  destroy  them,  and 
from  which  they  recover  and  again  become  normal.  This  is 
seen  most  often  in  irritations  of  the  septal  gingivae  from  food 
having  been  crowded  between  the  teeth.  Here  the  pull  of  the 
fil)ers  may  be  so  reduced  that  the  teetli  will  actually  stand  apart 
after  the  food  has  been  removed.  But  by  care,  the  fibers  will 
recover  their  tone  and  the  closeness  of  the  contact  will  be 
restored.  This  has  been  made  use  of  extensively  in  the  slow 
wedging  process  in  filling  teeth.  The  constant  pressure  by  the 
wedge  causes  the  fibers  to  relax,  and  they  permit  the  teeth  to  be 
separated  a  considerable  distance.  After  the  wedge  has  been 
removed,  however,  the  fibers  recover  their  tone,  and  draw  the 
teeth  back  into  close  contact. 

Labial  movement  of  upper  incisors.  Wlien  deposits  of 
serumal  calculus  on  the  lingual  surfaces  of  the  upper  incisors 
cause  the  detachment  of  a  portion  of  the  peridental  membrane 
and  the  formation  of  pus  pockets,  the  2^?/Z/  of  the  fibers  in  the 
lingual  direction  is  weakened,  and  the  tendency  is  for  the  pull 
of  the  fibers  of  the  labial  side  to  move  these  teeth  labially,  so  that 
they  begin  to  perceptibly  protrude.  At  first  this  movement  is 
so  slow  that  the  patient  will  not  notice  it,  and  also  the  disease 
progresses  so  slowly  and  painlessly  as  to  pass  unobserved.  But 
after  considerable  time  the  patient's  friends,  it  may  be,  will 
first  call  attention  to  the  increasing  prominence  of  the  incisor 
teeth.  Then  the  patient  in  some  alarm  may  consult  his  dentist. 
Unless  a  very  critical  examination  is  made  the  cause  of  the 
movement  may  not  be  discovered,  for  in  most  of  these  cases  the 
gingivae  on  the  lingual  side  give  a  fair  appearance.  The  tissue 
is  generally  thick  and  heavy  at  this  point,  and  especially  well 
adapted  to  conceal  the  disease  going  on  beneath  it.  It  therefore 
often  happens  that  the  cause  is  overlooked.  If,  however,  a 
subgingival  explorer  is  used  to  examine  the  attachment  of  the 
membranes  of  these  teeth  at  the  lingual  sides  of  the  roots,  deep 
pockets  will  be  found  with  a  slow  suppuration  in  progress,  which 


CHKONIC    SUPPURATIVE    PERICEMENTITIS.  177 

is  cutting  away  the  attachment  of  the  fibers  more  and  more, 
weakening  or  actually  destroying  the  pull  of  the  fibers  in  the 
lingual  direction.  Therefore,  in  the  cases  in  which  considerable 
destruction  of  the  attachment  of  the  peridental  membrane  has 
occurred  to  the  lingual  of  the  incisor  teeth,  an  amelioration  of 
the  conditions  may  occur  as  a  result  of  careful  treatment,  but 
there  will  generally  not  be  a  stoppage  in  the  movement  of  the 
teeth  to  the  labial,  because  the  harmony  of  pull  has  not  been  and 
can  not  be  restored. 

As  this  condition  goes  on  from  bad  to  worse,  the  forward 
movement  of  the  incisors  increases,  and  a  time  comes  when  the 
trans-septal  fibers,  which  normally  hold  the  contacts  of  the 
teeth  solidly  together,  become  involved  in  the  inflammation  and 
permit  loosening  of  the  contacts  between  the  anterior  teeth  and 
later  those  in  the  bicuspid  and  molar  regions,  progressively 
backward. 

This  loosening  of  the  contacts  gives  the  opportunity  for 
injury  to  the  septal  tissue  of  those  regions.  This  leads  to 
suppuration  after  suppuration,  which  goes  on  destroying  the 
membranes  of  the  teeth.  The  movements  of  the  upper  teeth 
bring  about  movements  of  the  lower  teeth,  resulting  in  the 
formation  of  pus  pockets  between  them.  Finally  suppuration 
is  present  generally  in  the  peridental  membranes  and  the  whole 
denture  becomes  a  wreck.  Figure  260  reproduces  two  views  of 
a  plaster  model  of  a  case  in  which  both  extensive  labial  move- 
ment and  wide  separation  has  occurred.  The  panoramic  view 
(Figure  261)  is  of  the  same  mouth. 

Teeth  may  move  forward  of  normal  position  of  labial  pro- 
cess. We  should  return  now  and  examine  the  forward  move- 
ment of  the  incisors  in  some  of  the  features  not  previously 
noticed.  The  question  may  be  asked:  How  is  it  possible  for 
the  incisors  to  move  so  far  forward  and  do  all  of  this  pulling  of 
the  other  teeth  with  them?  It  seems  that  the  roots  of  these 
teeth  actually  pass  the  outer  labial  line  of  the  alveolar  process 
as  it  stood  when  normal.  This  is  certainly  true  in  many  cases 
which  I  have  had  under  observation. 

This  is  accomplished  slowly,  step  by  step,  by  absorption 
from  the  labial  alveolar  process  on  its  inner  side  next  to  the 
peridental  membrane,  and  the  building  of  bone  on  its  labial  side. 
In  this  way  there  is  an  actual  movement  of  the  alveolar  process 
forward  which  carries  the  teeth  bodily  with  it.  Wliile  this  is  in 
progress  the  fibers  of  the  peridental  membrane  on  the  labial  side 
of  the  root  of  the  tooth  are  being  loosened  from  the  alveolar 

19 


178  SPECIAL   DENTAL   PATHOLOGY. 

process  in  space  after  space  and  replanted  farther  and  farther 
forward.  In  this  way  their  pull  is  kept  up  while  the  teeth  move 
labially,  until  it  is  with  difficulty  that  the  lips  can  be  made  to 
cover  them.  In  closing  the  mouth,  the  teeth  may  overlap  the 
lower  lip.  In  this  movement  the  crowns  of  the  teeth  move  much 
more  than  the  ends  of  the  roots.  In  some  cases  I  have  seen 
the  incisors  in  almost  a  horizontal  position.  A  movement  of 
the  incisal  edges  of  the  teeth  of  a  quarter  of  an  inch  forward 
is  no  exaggeration  of  what  actually  occurs.  Such  a  movement 
of  the  teeth  completely  changes  the  expression  of  the  face  and 
it  is  often  very  difficult  to  bring  the  face  into  correct  form  with 
artificial  teeth  because  the  residual  alveolar  ridge  has  moved  too 
far  forward.  Shakespeare  seems  to  have  known  something  of 
this  change  of  expression,  for  in  one  of  his  plays  he  says  of  a 
woman  acting  a  part:  ''She  is  not  young,  for  her  upper  teeth 
are  already  becoming  prominent. ' ' 

In  this  there  is  a  hint  of  the  slowness  of  this  movement  of 
tlie  teeth.  For  this  process  to  run  twenty-five  years  is  no 
exaggeration  of  statement.  It  is  so  slow  that  few  men  have 
observed  individual  cases  from  the  beginning  to  the  end.  It  is 
largely  for  this  reason  that  we  have  no  descriptions,  such  as  I 
have  given,  in  our  printed  records.  Especially,  dentists  have 
not  followed  cases  with  written  records  which  make  the  facts 
clear.  While  I  did  not  keep  records  of  these  cases  in  as  much 
detail  as  a  few  men  may  be  keeping  them  to-day,  my  records 
were  sufficient  to  enable  me  to  review  the  general  progress 
of  cases  from  their  beginning  until  the  teeth  were  finally 
lost.  There  is  not  a  record  of  the  cure  of  any  one  of  these 
cases  in  which  the  labial  movement  of  the  incisors  had  become 
established. 

These  are  among  the  most  hopeless  cases.  The  movement 
of  the  teeth  is  continuously  progressive.  As  mentioned  in  the 
treatment  of  these  cases,  the  inquiry  has  come  many  times  as  to 
the  possibility  of  moving  these  teeth  back  into  place  and  keeping 
them  there.  I  have  generally  advised  that  they  be  extracted. 
If  this  is  done  before  the  separations  in  the  bicuspid  region  have 
begun,  the  loss  of  these  teeth  may  be  averted.  The  attempt  to 
retain  the  incisors  too  long  has  often  been  disastrous. 

Multiple  pocket  formation.  It  has  been  observed  that 
when  a  pocket  has  formed  on  the  proximal  side  of  the  root  of  a 
tooth,  or  of  the  two  teeth  on  either  side  of  an  interproximal 
space,  and  has  cut  away  the  trans-septal  group  of  fibers  uniting 
the  two  teeth,  it  frequently  happens  that  other  similar  pockets 


CHRONIC    SUPPQKATIVE    PERICEMENTITIS.  179 

soon  begin  to  form  on  the  proximal  sides  of  the  roots  of  neigh- 
boring teeth. 

Suppose,  because  of  a  faulty  contact,  there  is  an  injuiy  to 
the  septal  tissue  between  the  first  molar  and  the  second  bicuspid 
which  destroys  the  trans-septal  fibers.  Very  soon  a  similar 
injury  may  be  noted  between  the  first  and  second  molars.  If  the 
case  has  been  watched  closely  enough  it  will  be  found  that  the 
rule  mentioned  relative  to  the  labial  movement  of  the  upper 
incisors  because  of  pockets  on  the  lingual  sides  of  their  roots,  is 
followed.  That  is,  there  is  a  tendency  in  all  cases  of  pocket 
formation  for  the  teeth  to  move  away  from  the  diseased  side 
during  inflammatory  periods.  When  this  occurs,  because  of  the 
diseased  membranes  of  the  proximal  surfaces  of  the  molars,  the 
movement  is  more  difficult  because  it  is  in  the  line  of  the  arch 
instead  of  to  the  side  of  the  arch.  The  first  molar  will  be  forced 
hard  against  the  second  molar,  and  if  the  stress  is  sufficient,  the 
second  molar  will  be  moved  distally  very  slightly.  With  the 
abatement  of  the  inflammatory  movement,  this  stress  will  be 
relieved,  and  the  teeth  will  return  to  their  former  positions. 
This  movement  of  the  teeth  will  be  repeated  with  each  recurrence 
of  the  inflammation,  and  will  often  cause  some  slight  interfer- 
ence with  the  intercusping  of  the  teeth  with  those  of  the  opposite 
jaw,  which  tends  to  make  some  movement  of  the  teeth  at  every 
closure  of  the  bite.  This  has  its  disturbing  effect  and  is  par- 
ticularly liable  to  be  such  as  to  drive  the  first  molar  back  into 
its  former  position  and  food  may  be  forced  between  it  and  the 
second  molar,  thus  establishing  an  inflammation  of  the  septal 
tissue  in  this  space.  The  movement  of  the  second  bicuspid 
mesially  exerts  a  similar  pressure  against  the  first  l)icuspid,  and 
by  the  same  process  food  will  be  forced  past  the  contact  into  that 
septal  space  also.  As  these  movements  continue  there  comes  a 
loosening  of  the  contacts  of  the  neighboring  teeth,  and  generally 
through  the  arch,  by  interference  with  the  fibers  which  form  the 
trans-septal  groups,  the  function  of  which  is  to  hold  the  teeth 
solidly  against  each  other  in  the  line.  It  seems  to  make  little 
difference  what  causes  the  inflammation  of  the  septal  tissue  first 
involved. 

These  inflammatory  movements,  occurring  in  the  septal 
tissues,  cause  these  groups  of  fibers  to  lose  their  tonicity.  This 
is  seen  also  in  the  fibers  of  the  peridental  membrane  in  acute 
apical  pericementitis  occurring  as  the  beginning  of  alveolar 
abscess.  The  tooth  often  becomes  very  loose  over  night.  This 
loss  of  tone  is,  indeed,  the  common  effect  of  the  involvement  of 


180  SPECIAL    DENTAL   PATHOLOGY. 

near-by  tissues  in  inflammation.  The  result  is  a  series  of 
inflammations  affecting  a  number  of  teeth,  or  the  septal  tissues 
generally. 

When  I  first  noticed  the  tendency  in  this  disease  to  spread 
from  one  septal  space  to  another,  my  thought  was  directed  to 
some  special  infection  as  the  cause.  I  studied  this  very  thor- 
oughly for  a  number  of  years.  Many  times  I  felt  assured  that 
the  supposition  was  correct,  but  in  the  long  run  of  observation 
the  proof  failed.  The  study  of  the  movements  of  the  teeth  in 
local  inflammatory  conditions  and  the  disturbance  of  the  con- 
tacts which  occurs,  together  with  the  increased  freedom  of  move- 
ment of  the  teeth  as  the  disease  progresses,  and  finding  of 
lodgments  in  neighboring  septal  spaces,  furnishes  very  con- 
vincing proof  that  the  spread  of  the  disease  from  contact  to 
contact  is  as  described  above. 

The  dentist  who  has  a  considerable  number  of  patients 
under  observation,  who  present  the  beginnings  of  this  disease, 
having  but  one  or  two  septal  spaces  involved,  and  will  carefully 
examine  neighboring  contacts  from  time  to  time,  as  to  their 
comparative  tightness,  studying  the  liability  of  food  being 
forced  onto  the  septal  tissue,  and  frequently  finding  that  food 
has  been  forced  through  the  contacts,  will  soon  become  con- 
vinced that  this  purely  mechanical  cause  of  the  spread  of  disease 
from  one  interproximal  space  to  another  is  explained  by  the 
results.  For  the  present,  at  least,  it  seems  best  to  rest  the  case 
on  this  proposition. 

Open  contacts  resulting  from  movements  of  teeth  may  be 
observed  in  many  of  the  illustrations.  Figures  234,  235,  244, 
245,  260  and  261  all  show  separations  which  appear  to  have  been 
brought  about  as  described  above. 

Gingival  abscess,  septal  abscess  and  lateral  alveolar  abscess. 
An  acute  abscess  occasionally  develops  in  the  investing 
tissues  of  the  teeth  in  connection  with  the  progress  of  these 
ordinarily  chronic  suppurations,  and  these  abscesses  are  named 
according  to  the  tissue  in  which  each  occurs.  If  for  any  reason 
the  pus,  which  is  formed  in  the  depth  of  a  pocket,  is  prevented 
from  escaping  alongside  the  root  and  into  the  mouth  between 
the  crown  of  the  tooth  and  the  margin  of  the  gingiva,  it  may 
invade  the  overlying  soft  tissue  and  develop  within  a  few  hours 
an  abscess  with  all  the  symptoms  of  an  acute  suppuration.  If 
the  pus  pocket  is  on  the  labial,  buccal  or  lingual  side  of  a  root 
and  is  not  deep,  the  abscess  will  tend  to  point  in  the  overlying 


CHRONIC    SUPPURATIVE   PERICEMENTITIS.  181 

gingivae,  and  this  is  termed  a  gingival  abscess.  It  the  pocket  is 
on  the  proximal  surface  of  a  root,  the  septal  tissue  will  be  princi- 
pally involved,  and  the  condition  is  designated  as  a  septal 
abscess.  If  the  pus  pocket  is  deep,  the  abscess  will  tend  to  point 
on  the  gum  over  the  edge  of  what  remains  of  the  alveolar  pro- 
cess, or  may  penetrate  the  process.  This  is  a  lateral  alveolar 
abscess.  Figure  262  is  from  a  plaster  model  of  a  case  which 
presented  with  a  lateral  abscess  to  the  buccal  of  the  upper  sec- 
ond bicuspid.  Several  drops  of  pus  were  obtained  when  the 
swelling  was  lanced.  The  pulps  were  vital  in  all  of  the  teeth 
shown.  Figure  263  illustrates  the  destruction  of  tissue  by  a 
septal  abscess.     Figure  230  is  also  of  a  case  of  lateral  abscess. 

A  case  was  brought  by  a  dentist  to  the  School  Clinic  for 
diagnosis.  The  symptoms  were  extreme  soreness  of  the  upper 
second  bicuspid  and  first  molar  and  swelling  and  inflammation 
of  the  tissues  about  the  teeth,  with  much  pain.  This  had  been 
supposed  to  indicate  acute  alveolar  abscess.  There  was  no 
caries.  The  dentist  had  cut  into  the  first  molar,  expecting  to 
find  a  dead  pulp,  but  found  the  pulp  alive.  He  had  then  cut  into 
the  second  bicuspid  and  found  its  pulp  alive  also.  Then  he  cut 
into  the  second  molar,  and  finally  into  the  first  bicuspid,  and 
found  the  pulps  in  these  teeth  were  alive.  He  then  brought 
the  case  to  me.  I  found  the  septal  tissue  between  the  second 
bicuspid  and  first  molar  very  much  swollen,  with  a  rather  wide- 
spread inflammation.  The  proximal  surfaces  of  these  two  teeth 
stood  apart.  Taking  a  very  sharp  narrow  blade,  I  pressed  the 
handle  far  back  into  the  cheek  of  the  o])posite  side  of  the  mouth, 
from  which  position  I  entered  the  point  of  the  blade  into  the 
swollen  septal  tissue  between  the  second  bicuspid  and  first  molar 
from  the  lingual  side.  Pus  welled  out  around  the  blade.  Thia 
was  a  septal  abscess,  the  original  cause  of  which  was  an  open 
contact  which  permitted  stringy  food  to  pass.  Two  days  later, 
when  soreness  had  abated,  I  found  some  food  debris  still  lying 
deep  in  the  space  beside  the  first  molar. 

Differential  diagnosis  from  true  alveolar  abscess.  As  in 
the  above  case,  such  abscesses,  and  more  especially  lateral 
alveolar  abscesses,  are  sometimes  mistaken  for  true  alveolar 
abscesses.  In  making  a  differential  diagnosis,  an  examination 
should  be  made  to  determine  whether  or  not  the  pulps  of  the 
teeth  are  alive.  If  so,  this  excludes  true  alveolar  abscess.  A 
peridental  membrane  explorer  should  be  entered  between  the 
gingiva  and  the  crown  and  passed  alongside  tlie  root  until  it 
passes  into  the  depth  of  the  pocket.     If  the  tissues  are  thus 


182  SPECIAL   DENTAL    PATHOLOGY. 

shown  to  have  been  detached  to  a  depth  corresponding  to  the 
position  of  the  abscess,  the  diagnosis  is  clear.  As  such  an  exam- 
ination is  often  very  painful,  it  may  be  best  to  use  the  lance  first, 
as  this  is  indicated  anyway.  In  the  literature  these  lateral  and 
septal  abscesses  have  been  spoken  of  a  number  of  times  as  the 
beginning  of  disease  of  the  peridental  membrane,  evidently  in 
cases  in  which  the  previously  formed  pus  pockets  have  been 
overlooked. 

Another  condition  of  extreme  soreness  occurs  frequently  in 
the  latter  part  of  the  progress  of  this  disease,  when  the  peri- 
dental membrane  is  being  stripped  from  the  apex  of  the  root,  or 
when  the  apex  of  the  root  is  very  closely  approached.  In  these 
cases  the  symptoms  closely  similate  those  of  acute  apical  peri- 
cementitis, or  the  beginning  of  alveolar  abscess,  and  if  the  pulp 
of  the  tooth  is  alive,  it  generally  dies  as  a  result  of  the  extension 
of  the  suppurative  process.  In  all  cases  in  which  there  are  deep 
pockets,  with  or  without  the  formation  of  abscesses,  it  is  impor- 
tant that  the  condition  of  the  pulp  be  ascertained. 

Admixtures  of  suppurative  pericementitis  and  inflammations 

CAUSED  BY  deposits  OF  SALIVARY  CALCULUS. 

Thus  far  I  have  spoken  of  chronic  suppurative  pericemen- 
titis and  the  destructive  inflammation  caused  by  deposits  of 
salivary  calculus  as  entirely  distinct  conditions.  This  has  been 
done  to  impress  the  important  differences  which  exist.  In  most 
cases  the  distinction  between  the  two  is  sufficiently  clear,  but  in 
some  it  is  not.  Deposits  of  salivary  calculus  occur  frequently 
during  the  progress  of  suppurative  pericementitis.  Such  depos- 
its may  occur  either  before  the  formation  of,  or  during  the 
progress  of  the  pus  pocket  witliout  being  in  any  way  connected 
with  it. 

The  appearance  of  the  gingivjp  in  the  two  conditions  is 
usually  very  different.  In  suppurative  pericementitis  there  is 
not  necessarily  any  salivary  calculus  present.  We  may  say  that 
generally  there  is  none,  if  the  cases  are  seen  early.  Yet  the 
presence  of  some  calculus  is  not  necessarily  excluded.  "When 
salivary  calculus  is  causing  inflammation  of  the  gingivjp,  the 
presence  of  the  calculus  is  very  apparent,  and  the  reddening  of 
the  gingivae  is  usually  pronounced  over  a  considerable  area,  or 
including  from  two  or  more  teeth  to  a  large  part  of  the  free 
gingivae.  In  this  the  septal  gingivgp  are  most  generally  not 
included  until  considerable  progress  has  been  made.  Salivary 
calculus  does  not  generally  lead  to  the  formation  of  pus  pockets 


CHRONIC    SUPPUBATIVE    PERICEMENTITIS.  183 

during  its  progress.  Its  general  tendency  is  to  destroy  the 
margin  of  the  free  gingivjE  and  shorten  them  as  a  first  effect. 
This  progresses  slowly  and  finally  invades  and  includes  the 
septal  tissue. 

In  the  early  stages  of  conditions  leading  to  the  formation  of 
pus  pockets,  small  points  of  inflammation  are  the  rule,  instead 
of  the  broader  areas  produced  by  salivary  calculus.  In  the 
larger  number  of  cases  these  will  at  first  be  confined  to  the  septal 
tissue  of  some  particular  space,  rather  than  to  the  free  gingivae. 
Usually  the  septal  tissue  begins  to  be  shortened  by  the  pressure 
of  food  into  the  space.  This  inflammation  of  the  septal  tissue 
generally  continues  for  a  long  time  before  the  beginning  of 
actual  injury  to  the  peridental  membrane. 

As  the  disease  of  the  gingivae  progresses  and  pus  pockets 
form,  the  gingivae  are  blunted;  their  borders,  or  crests,  are 
thickened.  Then  if  there  is  an  admixture  of  calculus  coming 
into  the  mouth  with  the  saliva,  it  will  be  more  liable  to  be  deposi- 
ted where  the  crests  of  the  gingivjE  are  thickened  than  else- 
where. Occasionally  cases  present  with  heavy  deposits  of 
salivary  calculus  about  teeth  which  have  deep  pockets.  The 
examination  of  many  cases  will  convince  one  that  the  deposit  of 
salivary  calculus  is  not  responsible  for  the  formation  of  the  pus 
pocket.  By  removing  the  calculus  and  examining  the  peridental 
membrane  with  the  subgingival  explorer,  one  may  get  an  under- 
standing of  the  actual  conditions.  If  there  are  no  distinct  pus 
pockets,  the  case  is  one  of  inflammation  caused  by  salivary 
calculus  alone.  If,  however,  the  gingivae  have  been  destroyed, 
and  much  shortened,  and  deep  pus  pockets  are  found,  especially 
on  proximal  root  surfaces,  the  case  is  one  of  chronic  suppura- 
tive pericementitis,  which  has  received  deposits  of  salivary  cal- 
culus later.  The  changes  in  the  gingivae,  which  have  occurred 
with  the  progress  of  the  pus  pocket,  have  afforded  the  oppor- 
tunity for  the  deposit  of  salivary  calculus. 

This  statement  may  not  be  easily  understood  by  those  who 
have  not  studied  closely  the  conditions  controlling  the  deposit 
of  salivary  calculus  after  it  comes  into  the  mouth  with  the 
saliva.  Any  blunting  or  thickening  of  a  gingiva  as  it  lies 
against  a  tooth  will  present  the  opportunity  for  a  deposit,  while 
the  same  place  would  not  collect  calculus  before  the  blunting  or 
thickening  of  the  gingiva  occurred.  The  effect  of  this  condi- 
tion should  have  careful  study. 

Pus  pockets  may  occasionally  occur  in  connection  with 
inflammations  caused  by  deposits  of  salivary  cnlculiis,  but  the 


184  SPECIAL   DENTAL   PATHOLOGY. 

pockets  are  generally  much  broader,  reaching  more  around  the 
root  of  the  tooth.  Indeed  they  differ  so  much  from  those  occur- 
ring from  the  injuries  mentioned  that  there  should  be  little  diffi- 
culty in  diagnosis.  They  are  not  present  in  the  beginning  of 
salivary  deposits,  or  at  a  time  when  treatments  should  be  under- 
taken, but  occur  most  in  the  later  stages.  Indeed  in  the  later 
stages  the  two  conditions  come  to  look  more  and  more  alike.  In 
the  last  stages  of  suppurative  pericementitis  we  will  often  find 
considerable  of  the  gum  tissue  standing  up  about  the  teeth,  while 
in  the  final  stages  of  the  inflammations  caused  by  salivary  cal- 
culus there  will  be  practically  no  gum  tissue  left. 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  185 


TREATMENT  OF  CHRONIC  SUPPURATIVE 
PERICEMENTITIS. 

ILLUSTRATIONS:    FIGURES  205-295. 

In  the  treatment  of  the  pus  pocket,  first  consideration  should 
be  given  to  the  relationship  which  such  foci  of  infection  bear  to 
general  systemic  conditions.  It  has  been  sufficiently  demon- 
strated that  many  remote  lesions  which  often  shorten  the  life  of 
the  individual  are  the  result  of  these  infected  pockets.  This 
being  the  case,  the  first  rule  of  practice  must  be  to  protect  our 
patients  from  this  source  of  systemic  poisoning.  The  question 
of  the  service  which  teeth  with  pockets  may  be  giving  in  mastica- 
tion should  have  no  weight  as  against  the  general  health.  No  set 
of  natural  teeth  with  many  of  these  pockets  about  their  roots  is 
enough  better  in  mastication  than  artificial  teeth,  to  justify  one 
in  jeopardizing  the  health  of  the  individual  by  their  retention. 

Our  consideration  of  the  general  health  should  not  be  based 
on  the  apparent  or  even  the  actual  physical  condition  of  the  par- 
ticular patient  at  a  given  time,  but  rather  on  the  danger  to  his 
future  health.  Many  of  the  secondary  systemic  lesions  are 
incurable  when  they  have  progressed  sufficiently  to  be  recog- 
nized. We  are  not  justified  therefore  in  permitting  patients 
who  are  apparently  well  to  go  about  with  such  foci  of  infection 
in  their  mouths.  While  we  recognize  the  fact  that  the  resistance 
of  some  individuals  is  sufficient  to  overcome  these  poisons  for 
many  years,  possibly  to  old  age,  yet  no  one  can  be  certain  at  any 
given  time  that  such  a  person  is  really  free  from  injury.  Our 
highest  duty  in  the  management  of  these  cases  is  to  free  our 
patients  from  the  danger  in  which  they  are  placed  by  such  a 
chronic  suppuration. 

The  key  to  the  treatment  of  suppurative  pericementitis  is  in 
the  statement  that  suppurative  detachments  of  the  peridental 
membrane  are  permanent  detachments.  This  fact  should  be 
constantly  foremost  in  the  mind  of  the  dentist,  as  it  naturally 
divides  our  consideration  of  the  treatment  into  preventive,  palli- 
ative and  radical.  Preventive  treatment  must  be  that  which  will 
in  each  case  prevent  or  tend  to  prevent  those  conditions  which 
result  in  suppuralivo  detnelimoTit,'^.     Pnllintivc  fi-ontmont  should 


186  SPECIAL   DENTAL   PATHOLOGY. 

be  such  as  will  keep  the  tissues  overlying  detached  areas  in  the 
best  possible  condition  and  thus  retard  further  detachments. 
Eadical  treatment  should  be  emploj^ed  to  cure  this  disease  by 
root  amputation  or  extraction. 

Preventive  treatment,  which  is  by  far  the  most  important, 
consists  of  (a)  the  maintenance  of  the  gingivae  in  good  health, 
and  (b)  the  detection  of  inflammations  and  their  cure  before 
serious  detachment  has  occurred.  Palliative  treatment  is  to  be 
applied  in  those  cases  in  which  detachment  has  occurred,  but  in 
which  conditions  are  such  that  the  effort  is  to  be  made  to  keep 
the  cases  under  control.  Radical  treatment  by  root  amputation 
or  extraction  is  indicated  in  cases  in  which  it  seems  unwise  to 
try  or  to  continue  palliative  treatment. 

Preventive  Treatment. 

All  that  has  been  said  heretofore  relative  to  the  treatment 
of  the  various  forms  of  gingivitis  is  essentially  preventive 
treatment  of  suppurative  pericementitis.  The  inflammations  of 
the  gingivae,  as  such,  are  of  little  consequence  and  require  treat- 
ment principally  for  the  purpose  of  preventing  involvements  of 
the  deeper  tissues. 

The  plan  for  preventive  treatment. 

The  treatment  for  prevention  can  be  effective  only  as 
it  is  undertaken  seriously  and  systematically.  The  plan  must 
include:  (1)  The  careful  examination  of  the  gingivae  as  a  part 
of  the  routine  examination  of  eacli  mouth;  (2)  a  record  of  the 
areas  of  inflammation  observed;  (3)  a  study  of  the  cause  of 
each  such  area;  (4)  the  treatment  necessary  to  remove  the 
cause;  (5)  the  careful  training  of  the  patient  in  the  care  of  the 
mouth;    (6)  subsequent  examinations. 

This  service  should  come  to  be  a  considerable  part  of  the 
practice  of  each  dentist.  It  should  be  carried  out  along  the 
same  general  lines  which  have  already  been  discussed  in  the 
treatment  of  inflammations  caused  by  deposits  of  salivary  cal- 
culus. Those  who  are  following  this  plan  in  the  most  thorough 
manner  are  finding  that  there  is  no  end  to  the  watchfulness 
required  for  most  patients.  In  many  mouths  changes  occur 
during  each  year  which  lead  to  new  inflammations.  Wear  of 
proximal  surfaces,  wear  of  occlusal  surfaces,  slight  movements 
of  teeth,  decays,  accidents,  etc.,  all  tend  to  change  conditions  so 
that  the  mouth  which  is  free  from  gingivitis  at  the  close  of  a 
series  of  operations  may,  within  six  months,  present  several 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  187 

new  areas.  It  should  be  quite  readily  appreciated  that  mouths 
which  are  thus  closely  watched  should  not,  and  generally  do  not, 
develop  pericementitis. 

Preventive  treatment  must  be  by  general,  practitioner  of 
DENTISTRY.  It  will,  I  think,  be  realized  that  the  treatment  of  the 
beginnings  of  disease  of  the  gingivae  belongs  to  the  general  prac- 
tice of  dentistry  in  just  the  same  way  as  the  correction  of  the 
abuses  of  the  gingivas  belongs  there.  The  first  element  of  this 
is  the  watchfulness  of  the  practitioner  for  the  beginning  injury. 
In  the  very  nature  of  things  this  must  be  discovered  by  the 
general  dental  practitioner,  and  not  left  to  specialists.  The 
rule  has  been  that  specialists  do  not  see  these  cases  early  enough 
to  apply  preventive  treatment. 

It  is  the  general  practitioner  who  must  discover  deposits  of 
salivary  calculus,  and  he  must  so  train  and  control  his  patients 
in  the  care  of  their  mouths  that  these  deposits  will  be  prevented, 
if  he  will  save  the  teeth  from  being  lost  from  this  cause. 
Likewise,  the  general  dental  practitioner  is  the  one  who  must 
discover  the  deposits  of  serumal  calculus  on  the  enamel  and 
remove  them  before  serious  suppuration  occurs.  The  opera- 
tions necessary  for  the  prevention  or  cure  of  most  of  the  injuries 
to  the  gingivae  are  the  routine  dental  operations,  carefully  and 
properly  done.  If  one  is  practicing  dentistry  at  all,  he  should 
be  acute  enough  to  see  these  things  and  skilful  enough  to  prevent 
or  correct  them.  Our  greatest  hope  for  the  future  is  in  the 
application  of  preventive  treatment  by  all  dentists,  rather  than 
in  the  use  of  palliative  treatment  by  specialists. 

Systematic  observation  and  institution  of  treatment 
EARLY.  Up  to  the  present  time  but  few  dentists  have  applied 
treatment  to  prevent  the  formation  of  pus  pockets,  the  large 
majority  having  deferred  treatment  until  after  the  pockets  have 
been  formed.  As  a  first  effort  in  practice  this  must  be 
exchanged  for  a  systematic  scheme  of  observation  for  the  detec- 
tion of  the  conditions  which  act  in  the  causation  of  pus  pockets, 
and  the  correction  of  these  before  they  have  done  serious  harm. 
We  have  become  so  inured  to  a  certain  phase  of  thought  toward 
the  soft  tissue  investments  of  the  teeth  —  a  phase  of  neglect  of 
their  appeals  for  help  —  that  a  change  to  greater  care  is  more 
of  a  task  than  most  persons  would  su])poso.  Somehow  the 
treatment  of  dental  caries  by  fillings  and  otlior  operations  has 
become  the  principal  service  of  the  dentist  to  such  an  extent  that 
the  soft  tissues  are  neglected  until  it  becomes  apparent  that 


188  SPECIAL    DENTAL   PATHOLOGY. 

severe  disease  has  developed,  and  that  there  is  imminent  danger 
that  the  teeth  will  be  lost. 

Care  to  avoid  injury  to  soft  tissues  in  all  operations. 
It  has  been  pointed  out  that  a  very  large  percentage  of  all  areas 
of  gingivitis  are  caused  by  operating  which  is  directly  abusive 
to  the  soft  tissues,  or  which,  on  account  of  lack  of  care  in  the 
finer  details,  is  indirectly  injurious  by  permitting  food  lodg- 
ments and  irritations.  These  have  become  so  common  that  they 
are  not  noticed,  or  are  given  no  consideration.  It  has  been  my 
constant  endeavor  in  the  writing  of  this  book  to  impress  the 
fact  that,  of  the  ordinary  dental  ills,  nothing  may  lead  to  more 
serious  consequences  than  one  little  area  of  gingivitis.  The 
highest  type  of  preventive  treatment,  therefore,  will  be  the  exer- 
cise of  the  finest  care  to  do  each  operation  so  well  that  the  soft 
tissues  will  suffer  no  injury.  This  may  only  be  done  as  the 
result  of  a  careful  study  and  training  by  each  man  for  himself. 
Every  area  of  gingivitis  presenting  should  be  critically  exam- 
ined to  determine  its  cause.  The  cause  should  then  be  removed 
and  the  case  observed  subsequently  to  know  the  result. 

Injuries  to  the  septal  tissues.  It  would  hardly  seem  neces- 
sary, after  what  I  have  said  of  the  injuries  to  the  septal  tissues 
and  the  results,  to  call  attention  to  them  again.  My  main  pur- 
pose is  to  refer  to  them  under  the  discussion  of  preventive 
treatment. 

The  correction  of  the  conditions  which  bring  about  the 
impaction  of  food  in  the  septal  spaces  must,  in  its  very  nature, 
be  done  by  the  person  who  is  also  filling  teeth.  The  regular 
practitioner  of  dentistry  must  be  trained  in  the  observation 
necessary  to  the  early  detection  of  these  injuries  and  must  be 
ready  to  correct  the  conditions  giving  rise  to  them  at  once. 
These  conditions  have  been  described.  Fortunately  there  is 
usually  sufficient  time  between  the  beginning  of  the  impaction 
of  food  into  a  given  space,  and  the  time  of  serious  injury  to  the 
peridental  membrane,  to  allow  for  its  discovery  and  treatment 
before  the  peridental  membrane  is  permanently  injured.  The 
greatest  element  needing  development  is  the  ability  to  see  these 
things  and  to  act  with  reasonable  promptness.  If  a  worn  con- 
tact in  a  given  case  is  causing  the  lodgment  of  food  in  the  septal 
space,  one  should  be  able  to  detect  the  shortening  of  the  septal 
gingiva  in  good  time  to  cut  a  cavity  in  one  of  the  teeth,  and 
liuild  a  filling  with  a  prominent  contact  that  will  prevent  food 
fi'om  passing,  and  to  key  up  that  part  of  the  arch  to  the  normal 
pressure  of  tooth  against  tooth.     Then,  as  rapidly  as  possible, 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  189 

the  patient  should  ))rmg  heavy  work  in  mastication  on  these 
teeth  to  increase  the  tonicity  of  their  membranes.  Usually  no 
other  treatment  is  necessary. 

In  other  cases  the  treatment  must  be  varied  to  meet  the 
cause  of  the  difficulty.  In  some  cases,  the  cause  of  the  inflam- 
mation will  be  obscure,  and  patient  study  will  be  required  to 
determine  it.  But  the  rule  is  that  the  progress  of  injury  will 
allow  reasonable  time  for  the  discovery  of  the  cause  and  its 
correction.  Under  no  circumstances  should  such  an  injury  fail 
to  receive  reasonably  prompt  treatment.  Such  a  case  begins  to 
try  the  strength  of  the  arch  early  sometimes,  and  if  treatment  is 
delayed,  a  number  of  other  contacts  may  be  leaking  food,  thus 
injuring  the  tissues  in  other  septal  spaces. 

Injuries  to  lingual  of  upper  incisors.  Injuries  to  the  lin- 
gual of  the  upper  incisors,  which  have  been  considered,  do  not 
occur  very  frequently,  but  when  they  do,  the  causes  usually 
become  very  distressing  on  account  of  the  gradually  increasing 
protrusion  of  the  teeth,  and  hopeless  in  that  they  may  not  be 
bettered  by  treatment.  For  this  reason  very  especial  watch 
over  these  gingivae  should  be  kept  up  continuously.  A  watch 
for  serumal  calculus  on  the  teeth  within  the  subgingival  space 
by  frequent  instrumental  examinations  should  always  be  a  habit 
of  practice,  because  this  calculus  is  covered  by  the  gingiva?  and 
is  hidden  from  view.  It  does  harm  of  a  more  serious  nature 
in  this  particular  place  than  elsewhere,  but  is  liable  to  do  serious 
harm  anywhere  that  it  may  be  lodged.  It  is  an  enemy  in  ambush 
that  one  should  look  for  as  a  habit  of  practice.  When  found 
anywhere  in  a  patient's  mouth,  it  should  be  removed  completely, 
and  frequent  examinations  made  at  fairly  regular  intervals  for 
its  return.     When  it  occurs  once,  it  is  liable  to  recur. 

Training  of  patients.  Patients  should  be  taught  to  brush 
the  gingivae  and  cleanse  the  subgingival  spaces  as  a  part  of  the 
routine  care  of  their  mouths.  In  addition  to  the  brushing,  one 
of  the  best  forms  of  treatment  for  keeping  the  gingivae  in  good 
health  is  to  wash  them  with  a  jet  of  water  from  the  syringe. 
In  those  cases  in  which  the  gingivae  show  too  much  redness, 
cases  in  which  deposits  of  serumal  calculus  are  most  liable  to 
occur,  this  treatment  is  very  effective.  I  have  found  the  ten- 
dency to  continuous  redness  to  abate  more  readily  under  the 
washing  with  the  syringe  than  any  other  treatment  which  I  have 
tried.  In  this  cleaning,  the  tissues  are  in  no  danger  whatever  of 
injury.  It  seems  to  be  especially  suited  to  keeping  the  gingivae 
throughout  the  mouth  in  a  fine  state  of  health,  and  it  is  worth 


190  SPECIAL   DENTAL    PATHOLOGY. 

while  to  train  patients  in  its  use.     The  manner  of  doing  this 
will  be  given  in  detail  under  Mouth  Hygiene. 

Palliatfvie  Treatment. 

Palliative  treatment  should  be  applied  to  those  cases  in 
which  detachment  has  occurred,  but  in  which  conditions  are  such 
that  the  eifort  is  to  be  made  to  keep  the  cases  under  control. 
This  generally  means  that  such  cases  will  require  the  best  of 
care  and  watchfulness  by  both  dentist  and  patient  so  long  as  the 
affected  teeth  remain  in  the  mouth. 

While  it  has  been  suggested  that  preventive  treatment  ends 
and  palliative  treatment  begins  with  a  suppurative  detachment 
of  the  peridental  membrane,  yet  the  line  between  the  two  may 
not  be  drawn  quite  so  sharply.  As  has  been  stated,  there  are 
many  slight  suppurations,  which  destroy  a  little  of  the  attach- 
ment of  the  membrane,  but  which  recover,  except  that  there  is 
no  reattachment  of  the  detached  fibers.  The  gingivre  recede 
a  trifle,  the  tissues  accept  a  new  line  of  attachment  and  there 
may  be  no  further  progress  of  the  case. 

Other  cases  occur  in  which  a  slight  pocket  remains  as  the 
result  of  a  suppuration.  The  overhang  tissue  may  not  hug  the 
tooth  as  closely  as  fonnerly,  depending  upon  the  extent  to  which 
the  free  gingivjp  fibers  have  been  cut  off,  and  the  space  receives 
accumulations  from  the  saliva,  including  pyogenic  organisms. 
In  addition,  there  is  apt  to  be  more  than  the  normal  amount  of 
serum  excreted,  on  account  of  the  changed  character  of  the 
tissue,  and  also  on  account  of  the  irritation  of  the  accumulations 
within  the  pocket.  This  is  likely  to  bring  a  deposit  of  semmal 
calculus,  which  will  increase  the  inflammation. 

Pockets  on  labial  and  buccal  surfaces  offer  the  best  oppor- 
tunity for  palliative  treatment,  because  the  teeth  are  less  liable 
to  move  lingually,  owing  to  the  resistance  of  the  curve  of  the 
arch;  proper  contacts  may  be  maintained  and  the  irritation 
caused  by  food  impactions  avoided. 

Many  cases  may  be  held  in  abeyance  for  a  long  time  by 
palliative  treatment,  particularly  if  only  one  or  two  teeth  are 
involved.  Sometimes  the  tissues  in  a  certain  interproximal 
space  may  be  rather  seriously  injured,  but  the  conditions  are 
such  that  a  good  contact  may  be  restored  and  maintained. 
If  the  pocket  is  not  deep,  or  if  there  has  been  sufficient  shrinkage 
of  the  septal  tissue  to  reduce  the  depth,  the  case  may  be  kept 
under  control  by  the  treatment  which  will  be  presented. 


chronic  suppurative  pericementitis.  191 

Plan  for  palliative  treatment. 

The  plan  for  palliative  treatment  should  consist:  (1)  The 
removal  of  deposits  and  care  of  the  tissues  by  the  dentist; 
(2)  care  by  the  patient;  (3)  subsequent  examinations  at  stated 
intervals. 

The  effort  should  be  to  prevent  pockets  from  becoming 
deeper,  by  clearing  up  the  present  suppuration  and  preventing 
a  recurrence.  Continued  cleanliness  of  the  pocket  will  more 
nearly  achieve  this  end  than  any  other  plan  of  treatment.  The 
dentist  should  remove  the  deposits,  clean  the  pocket  and  other- 
wise put  it  in  the  best  possible  condition  before  turning  the  case 
over  to  the  patient.  Then  the  care  by  the  patient  should  be  that 
which  will  remove  the  accumulations,  prevent  new  deposits  as 
far  as  possible,  and  keep  the  soft  tissue  in  the  most  healthy 
condition. 

All  that  has  been  said  in  the  treatment  of  inflammations 
caused  by  deposits  of  salivary  calculus  relative  to  the  earnest- 
ness with  which  the  dentist  should  arrange  for  the  management 
of  cases,  the  care  in  making  and  recording  examinations,  the 
impression  which  should  be  made  upon  the  patient  as  to  the 
importance  of  active  cooperation,  applies  with  equal  force  here. 
It  should  be  borne  in  mind,  and  the  patient  should  be  brought 
to  realize,  that  treatment  is  undertaken  to  prevent  cases  from 
progressing  by  preventing  reinfections  and  further  detachments, 
which  means  that  each  such  pocket  must  be  under  practically 
continuous  observation  and  treatment  as  long  as  the  tooth 
remains  in  the  mouth.     It  is  a  life-long  task. 

Removal  or  deposits  and  care  by  the  dentist. 

The  removal  of  deposits  of  serumal  calculus,  which  have 
occurred  either  upon  the  enamel  of  the  subgingival  spaces  or 
upon  the  cementum  within  the  pocket,  is  one  of  the  important 
matters  in  the  treatment  of  suppurative  pericementitis.  As  has 
been  said,  a  considerable  number  of  cases  present  in  which  no 
deposits  have  occurred  over  long  periods  of  time.  However, 
the  rule  is  that  deposits  do  occur,  although  there  is  the  widest 
possible  variation  as  to  the  rapidity  of  their  accumulation, 
depending  upon  the  amounts  of  calco-globulin  in  the  secretions, 
and  also  upon  the  quantity  of  serum  poured  out  into  the  pockets. 
Wliile  deposits  on  the  cementum  necessarily  occur  after  detach- 
ment, and  are  therefore  not  a  primary  cause  of  detachment, 
their  presence  serves  to  promote  the  progress  of  the  disease,  by 
increasing  the  inflammation  of  the  overlying  tissue.     Therefore, 


192  SPECIAL   DENTAL   PATHOLOGY. 

tlie  first  indication  in  treatment  is  for  the  removal  of  these 
deposits. 

For  cases  in  which  a  number  of  teeth  are  involved,  the  thor- 
ough removal  of  the  deposits  requires  the  most  painstaking 
technic  and  the  limit  of  persistence.  Attention  should  be  given 
to  a  particular  section  of  the  mouth,  or  to  a  few  teeth,  at  a 
sitting,  in  order  that  no  particle  of  deposit  may  be  missed.  This 
should  be  done  in  a  systematic  way,  to  include  eveiy  denuded 
surface. 

Instkuments.  The  technic  of  removal  is  practically  the 
same  as  that  already  mentioned  for  the  removal  of  deposits  from 
sul)giugival  spaces,  except  that  as  pockets  are  deeper,  the  diffi- 
culties in  manipulation  are  increased.  The  instruments  to  be 
used  are  the  same.  The  set  of  scalers  shown  in  Figure  266  was 
designed  primarily  for  the  purpose  of  reaching  the  various 
surfaces  of  roots  in  doing  this  operating. 

The  accompanying  radiographs  show  several  of  these 
instruments  in  their  proper  positions.  (See  Figures  268  to 
284.)  With  all  of  the  instruments  it  will  be  noticed  that  the  work- 
ing points  —  the  blades  —  are  practically  in  line  with  the  handle, 
which  is  an  essential  feature  to  accurate  manipulation.  (See 
Figure  265.)  The  greatest  length  of  blade  is  8  millimeters 
(nearly  one-third  of  an  inch) ;  this  is  considered  about  the  limit 
of  depth  of  pocket  in  which  this  plan  of  treatment  should  be 
employed.  Certainly  in  most  cases  pockets  of  this  or  even  less 
depth  will  be  kept  under  control  with  much  difficulty,  and  many 
teeth  with  pockets  of  this  depth  should  be  extracted. 

There  are  in  this  set  twelve  instruments.  Two  of  these  are 
peridental  membrane  explorers.  They  are  especially  designed 
for  feeling  the  line  of  attachment  of  the  peridental  membrane  to 
the  cementum.  These  have  smoothly  rounded  ends,  so  that  they 
will  not  injure  the  tissue,  and  may  be  carried  around  each  root 
with  the  end  following  the  line  of  attachment  of  the  tissue.  (See 
Figure  268.)  The  rougher  deposits  may  be  easily  detected  with 
these  instruments,  although  sharp  blades  should  be  used  to 
determine  the  exact  condition  as  to  finer  deposits.  There  is  a 
special  pair  of  explorers,  not  included  in  the  regular  set,  made 
with  longer  blades,  also  with  smoothly  rounded  ends;  these  are 
graduated  with  a  scale  of  fifteen  millimeters,  beginning  at  the 
end.  (See  Figure  267.)  In  making  examination  charts  these 
instruments  are  used  to  record  the  depth  of  pockets,  as  will  be 
explained  under  the  heading  of  Examinations  of  the  Mouth. 


CHRONIC    SUPPURATIVE   PERICEMENTITIS.  193 

There  are  six  pull  scalers,  in  three  pairs,  each  having 
blades  1.5  mm.  wide  and  8  mm.  long,  but  of  different  angles. 
These  are  all  made  with  curved  blades,  somewhat  similar  to 
spoons,  but  with  square  ends.  The  blades  of  one  pair  are  straight, 
as  viewed  from  one  direction,  but  have  a  very  slight  curve  as 
viewed  from  the  other  direction.  One  has  the  cutting  edge  look- 
ing toward  the  handle,  the  other  looking  away  from  the  handle. 
The  second  pair  has  the  formula  15-8-6,  and  the  third  pair 
15-8-12 ;  these  having  blades  at  angles  of  6  and  12  centigrades, 
respectively,  to  the  handles.  There  is  one  pair  of  push  scalers 
with  the  formula  15-8-12.  In  addition  there  is  a  sickle  form  and 
a  cleoid  form,  which  are  designed  to  reach  shallow  depths  on  the 
proximal  surfaces  of  front  teeth. 

Instrumentation.  In  the  upper  incisor  region,  the  straight 
instruments  may  be  used  for  the  major  part  of  the  operating  on 
all  four  surfaces  of  each  root,  although  those  of  6  centigrade 
angle  will  occasionally  be  found  more  convenient  for  proximal 
surfaces.  For  the  upper  bicuspids  the  same  instruments  may 
generally  be  used,  although  those  of  6  centigrade  angle  will 
more  often  displace  the  straight  blades.  (See  Figures  269,  270, 
273  and  274.) 

In  the  upper  molar  region  the  12  centigrade  blades  will 
generally  be  most  convenient.  In  many  mouths  the  6  centi- 
grade or  the  straight  blades  may  be  used  on  both  buccal  and 
lingual,  and  in  a  fair  percentage  on  the  distal  surface  of  the  first 
molar.  Sometimes  the  second  molar  may  be  reached  with  these 
instruments.  The  straight  pull  instrument  with  the  blade  look- 
ing toward  the  handle  is  to  be  used  on  distal  surfaces.  The 
corresponding  instrument,  with  the  blade  looking  away  from  the 
handle,  is  especially  well  adapted  for  reaching  the  region  of 
mesio-lingual  angles  of  the  roots  of  these  teeth.  (See  Figures 
275  to  278.) 

For  the  lower  incisors,  as  for  the  upper,  the  straight  instru- 
ments may  be  used,  although  those  of  6  centigrade  angle  will  be 
more  often  found  desirable,  particularly  at  the  mesio-  and  disto- 
lingual  angles.  The  sickle  blade  or  the  cleoid  may  often  be  used 
in  this  position.     (See  Figures  271  and  272.) 

For  the  lower  bicuspids  and  molars,  the  12  angle  blades 
may  frequently  be  used  on  all  surfaces,  although  the  6  angle 
will  often  be  more  convenient  for  the  bicuspids.  On  all  of  the 
lower  bicuspids  and  molars,  the  straiglit  instrnmont  with  the 
blade  looking  away  from  the  handle  will  be  found  to  reach  the 
ao 


194  SPECIAL    DENTAL   PATHOLOGY. 

mesio-lingual  angle  better  than  any  other.     (See  Figures  279 
to  284.) 

Finger  skill  very  essential.  This  set  of  scalers  is  consid- 
ered sufficient  in  number  and  variety  of  form  to  reach  all  posi- 
tions in  pockets  which  should  receive  palliative  treatment.  In 
fact  a  less  number  will  be  sufficient  for  the  more  skilful  opera- 
tors. The  most  essential  thing  for  the  thorough  scaling  of  roots 
is  the  development  of  proper  finger  skill.  Dentists  who  have 
not  trained  themselves  so  that  they  are  able  by  the  sense  of 
touch  to  find  each  particle  of  deposit,  and  to  so  locate  it  that  the 
instrument  may  be  properly  placed  for  its  removal,  will  not  be 
successful  in  scaling  operations,  even  though  they  have  the  larg- 
est conceivable  number  of  instruments.  This  is  a  skill  acquired 
by  long  training,  much  the  same  as  the  training  required  to 
master  the  finer  technique  of  the  piano. 

One  will  do  well  to  occasionally  test  his  ability  in  this  oper- 
ating, by  performing  the  most  thorough  possible  scaling  of  a 
root  which  is  to  be  extracted,  going  over  the  denuded  surface 
again  and  again,  until  every  particle  of  deposit  is  apparently 
removed.  An  examination  of  the  root  after  the  tooth  is 
extracted  will  reveal  the  thoroughness  or  lack  of  thoroughness 
of  the  teclmic  employed,  and  will  indicate  the  measure  of  success 
which  is  being  attained  in  similar  operations  on  teeth  which  are 
retained. 

Scalers  must  be  sharp.  It  is  absolutely  essential  that 
scalers  be  sharp  if  the  deposits  are  to  be  successfully  removed. 
The  deposits  are  usually  very  closely  adherent  to  the  cementum 
and  it  requires  both  a  very  sharp  blade  and  considerable  force, 
accurately  applied,  to  remove  them.  Isolated  nodules  may  gen- 
erally be  removed  with  less  difficulty  than  the  flatter  scale-like 
deposits.  In  cases  of  long  standing  almost  the  entire  cementum 
of  the  pocket  may  be  covered,  and  the  deposit  may  be  in  the  form 
of  a  tolerably  smooth  mass,  or  more  or  less  roughened.  The 
removal  of  such  a  deposit  is  much  more  difficult  than  of  the 
separate  nodules.  This  requires  the  most  careful  technic  and 
persistence  and  the  employment  of  the  sharpest  possible  blades. 
These  instruments  must  be  delicate  and  of  such  form  that  they 
ma}"  be  manipulated  within  the  pocket,  without  unnecessary 
injury  to  the  soft  tissues.  The  blades  should  be  sharpened 
often,  but  should  not  require  more  than  a  movement  or  two  on 
the  oil-stone  with  light  pressure.  The  blades  of  the  pull  scalers, 
particularly,  may  be  worn  away  in  a  short  time  by  too  much 


CHKONIC    SUPPURATIVE    PERICEMENTITIS.  195 

grinding  on  the  stone.     The  pull  scalers  must  be  frequently 
replaced  by  new  instruments. 

As  a  rule,  the  pull  scalers  will  cause  less  injury  to  the  soft 
tissues  than  the  push  scalers,  especially  by  other  than  the  most 
skilful  operators.  The  pull  scalers  may  be  verj^  carefully  car- 
ried to  the  depth  of  the  pocket,  the  edge  of  the  blade  being  held 
against  the  surface  of  the  root,  feeling  the  deposit  as  the  blade 
passes  over  it,  until  the  movement  is  stopped  by  the  end  of  the 
instrument  coming  in  contact  with  the  attachment  of  the  mem- 
brane. Then  the  blade  should  be  held  hard  against  the  root  and 
drawn  out  in  an  effort  to  bring  the  deposit  with  it.  These 
instruments  are  used  as  hoes.  If  the  instrument  does  not  bring 
the  deposit  away,  the  failure  is  usually  due  either  to  the  fact 
that  the  blade  is  not  sharp,  or  that  it  was  not  held  in  proper 
relation  to  the  root,  or  the  force  applied  was  insufficient. 

.  In  the  use  of  the  push  scalers,  the  edge  of  the  blade  is  placed 
on  the  enamel  near  the  gingival  line,  and  the  instrument,  while 
held  close  against  the  root,  is  carried  toward  or  to  the  full  depth 
of  the  pocket,  the  attempt  being  made  to  cut  the  deposit  away 
from  the  root  with  the  movement.  The  finger  position  should 
be  such  that  the  pushing  movement  is  under  complete  control  by 
a  rest  of  fingers  on  neighboring  teeth,  or  possibly  by  a  finger  of 
the  opposite  hand,  to  prevent  the  instrument  from  plunging  into 
the  soft  tissue  as  the  deposit  breaks  away,  or  if  the  instrument 
should  slip.  In  positions  in  which  there  is  good  access  and 
opportunity  for  perfect  control,  these  instruments  are  more 
effective  than  the  pull  scalers.  The  angle  of  bevel  of  the  blades 
is  such  that  they  will  hold  their  edge  better,  and  remain  sharp 
longer. 

Leave  roots  smooth.  The  effort  should  be  to  remove  all 
of  the  deposit  and  leave  the  surface  of  the  root  as  smooth  as 
possible.  Some  writers  have  contended  that  a  portion  of  the 
cementum  should  be  planed  off  in  the  effort  to  remove  all  of  it 
that  had  become  saturated  with  the  products  of  the  suppurative 
process.  There  are  several  reasons  why  this  seems  to  me  to  be 
impractical.  The  cementum  is  so  porous  that,  in  cases  in  which 
the  infection  has  been  in  progress  for  a  time,  it  will  become  satu- 
rated with  the  products  of  suppuration.  Even  in  very  recent 
cases,  if  it  were  possible  to  know  when  one  had  removed  the 
infected  portion,  we  could  not  expect  to  get  a  normal  reattach- 
ment, because  of  the  disappearance  of  the  cementoblasts  and 
fibers  from  the  detached  tissue.  The  case  would  soon  become 
reinfected  and  the  previous  condition  re-established.     Even  if 


196  SPECIAL   DENTAL   PATHOLOGY. 

in  rare  instances  an  attacliment,  such  as  is  obtained  in  cases  of 
planted  teeth,  should  occur,  this  has  been  shown  to  be  physio- 
logically unstable.  The  excessive  planing  of  the  cementum  will 
often  render  vital  teeth  hypersensitive,  making  future  scaling 
operations  very  painful.  Such  hypersensitiveness  of  a  single 
tooth  may  reflexly  cause  the  formation  of  secondary  dentin 
within  all  of  the  teeth. 

In  many  cases  the  cementum  of  a  pocket  is  considerably 
softened  by  the  growth  of  acid  forming  micro-organisms  within 
the  pocket.  The  acid  dissolves  the  calcium  salts  from  the 
cementum,  softening  it  in  the  same  manner  in  which  dentin  is 
softened  by  caries.  Cementum  in  this  condition  is  very  easily 
removed  with  a  sharp  instrument. 

Pain  in  scaling  opeeations.  Pain  in  connection  with 
scaling  operations  is  caused  in  some  cases  by  the  sensitiveness 
of  the  pulp  of  the  tooth  and  in  some  on  account  of  the  inflamma- 
tion of  the  peridental  membrane.  There  is  no  physiological 
provision  for  the  transmission  of  sensation  through  the  cemen- 
tum. The  ends  of  the  dentinal  fibrils,  just  beneath  the  cemen- 
tum, must  receive  some  stimulation  for  sensation  to  be  conducted 
through  to  the  pulp.  Theraial  changes  may  be  sufficient  to  cause 
pain  in  cases  where  the  recession  of  the  gum  has  exposed  the 
cementum,  or  in  the  irrigation  of  pockets  with  water  which  is 
too  hot  or  too  cold.  Usually  pain  caused  by  instruments  in 
scaling  is  the  result  of  the  removal  of  the  cementum,  exposing 
the  surface  of  the  dentin.  The  area  of  dentin  immediately 
below  the  cementum  is  more  sensitive  than  closer  in  toward  the 
pulp,  because  of  the  branching  of  the  ends  of  the  tubules,  pre- 
senting many  fine  sensitive  filaments  in  this  portion  of  the 
dentin. 

In  cases  in  which  there  is  continual  complaint  of  pain  on 
account  of  the  sensitiveness  of  teeth  with  pockets,  the  only 
remedy  for  such  pain  is  to  remove  the  pulp.  This,  of  course, 
relieves  the  difficulty  at  once.  However,  pulps  should  not  be 
removed  without  a  definite  indication  for  so  doing.  The  prac- 
tice of  removing  pulps,  which  has  been  recommended  as  being 
beneficial  in  the  treatment  of  suppurative  pericementitis,  is 
unwarranted. 

Pain  within  the  peridental  tissues  in  connection  with  scaling 
operations  is  usually  due  to  hypersensitiveness  or  to  abuse  of 
the  tissues.  The  hypersensitiveness  may  be  reduced  by  thor- 
ough irrigation  of  the  pocket  on  two  or  three  successive  days, 
or  a  solution  of  novocain  may  be  injected  into  the  surrounding 


^ 


Fig.  265.  a,  b,  c  and  d,  Tnstrunionts  wronjjly  coiitra-au^lcd.  Tlicir  points  are 
so  far  from  the  line  of  the  central  axis  of  tlie  sliaft  that  th(\v  ineiine  to  twist, 
or  turn,  in  the  fingers  when  the  effort  is  made  to  cut  witli  them.  Tliey  are  out  of 
lialance.  e,  f  and  G,  Instruments  correctly  contra-any;led.  Points  are  l)rou;riit  close 
enough  to  the  line  of  tlu»  central  axis  so  that  they  will  not  he  imdined  to  twist,  or 
turn,  in  the  fingers  when  the  effort  is  made  to  cut  with  tiiem.     They  iire  well  tiahmced. 


*20 


Fig.  2()f). 


Fig.  267. 


descHhtl  1n^;h«^f  f  """f  ^''  ^«'-/«"i"vi"g  deposits  of  serumal  calculus.     These  are 
described  in  the  text,  and  some  of  the  positions  in  use  are  shown  in  Figures  268  tS 

nullimeL^sJ.lefscurin"H,?n'l'   '""^l^'''  ^'"'   "'^'^«"-"g  the  d.pth  of  pockets.     A 


IHI^V 


J"u 


Fig.  269. 


Fig.  270. 


Hi 


l''i(,.  I'Tl.  Fig.  272. 

Figs.  268  to  284.  A  series  of  radiojjraplis  illustratiiifr  the  use  of  the  scalers  in 
removing  deposits  of  serumal  calculus.  Tlic  pockets  in  this  case  were  too  deep  to 
require  scaling  operations,  as  extraction  of  all  of  the  teeth  was  indicated.  This  cas<' 
was  usi'd  to  better  illustrate  the  instrument  positions. 

Fig.  268.  This  shows  one  of  the  peridental  menibraue  explorers  which  has  been 
carried  down  to  the  attachment  of  the  soft  tissue  to  the  cementuin  on  the  labial  side 
of  a  lower  lateral  incisor.     The  rounded  end  of  the  instrument  is  nicely  shown. 

Fig.  269.  The  almost  straight  pull  scaler,  with  blade  looking  toward  handle, 
in  position  on  the  distal  surface  of  an  upper  lateral  incisor. 

Fig.  270.  The  almost  straight  pull  scaler,  with  blade  looking  toward  han<lle.  in 
position  on  the  mesial  surface  of  an  upper  central  incisor. 

Fig.  271.  The  15-8-6  pull  scaler  in  position  at  the  mesio-lingual  angle  of  a 
lower  lateral  incisor. 

Fig.  272.  The  almost  straight  pull  scaler,  with  blade  looking  toward  handle,  in 
position  on  the  distal  surf;ice  of  a    l()\\er  lateral   incisor. 


ILij 


Fig.  273. 


Fig.  274. 


Fjg.  275. 


Fig.  276. 


Li' it 


Fig. 


F:g.  27S. 


Fig.  268  to  2S4.  A  series  of  radintrriiiilis  illustrating  tlic  ii>i'  of  tin-  scalers  in 
removing  deposits  oi'  seminal  calculus.  Tlie  jxickcts  in  this  case  were  too  deep  to 
require  scalinfj  operations,  as  extraction  of  all  of  the  teeth  was  indicated.  Tliis  (-ase 
was  used  lo  lietter  illustrate  the  instrument   ])ositions. 

Fig.  27.'{.  The  almost  straijijht  pull  scaler,  with  Made  l(Pokiii<i  away  from  handle, 
in  position  at  niesie  lingual  angle  of  upper  s nd  bicuspid. 

Fig.    271.      'The    l."(-S-(!    pidl   scaler    in    position    on    lingual    surfac f   u[>per   first 

bieuspifl. 

Fig.  275.  The  almost  straight  pull  scaler,  with  lila<le  looking  away  from  handle, 
in  position  on  mesial  snrfaee  of  lingual  root  of  ui>per  first   un>lar. 

Fig.  276.  The  almost  straight  pull  scaler,  with  blade  looking  toward  handle,  in 
position  on  distal  surface,  of  upper  first  m(dar. 

Fig.  277.  The  ]5-8-12  scaler  in  position  on  lingual  surface  of  upper  second 
molar. 

Fig.  278.     The  15-8-12  scaler  in  position  on  buccal  surface  of  upper  first   nu)|ar. 


Fig.  279. 


l'"ii;.   :;mi. 


*  il   * 


Fig.  281. 


■^"^rD 


Fig    282. 


Fig.  28.3. 


^r 


Fig.  284. 


Figs.  2fiS  to  2S4-.  A  series  (if  i;iilii>|iriipiis  illusti;it  iei;  the  use  of  tlie  sealers  in 
removing  deposits  of  serunial  ealciihis.  The  pockets  in  this  ease  were  too  deep  to 
require  sealing  operations,  as  extraction  of  all  of  the  teeth  was  indicated.  This  case 
was  used  to  better  illustrate  the  instnnnciil    positions. 

Fig.  279.  The  l.'i-S  (i  |inll  <cahM-  in  position  on  the  nu'sial  surface  of  the  lower 
first  bicuspid. 

Fig.  280.  The  almost  straight  pull  scaler,  with  blade  locking  toward  handle,  in 
position  on  distal  surface  of  lower  first   bicuspid. 

Fig.  281.  The  alitu)st  straight  pull  scaler,  will:  bla.le  looking  toward  h;indle.  in 
position   on   distal  surface  of  lower  first  molar. 

Fic.  282.  The  l.')-8-12  scaler  in  position  on  distal  sml'ace  of  lowei-  lirst  nudar, 
apiiroach  being  through  the  buccal  enil)rasure. 

Fig.  288.  The  abnost  straight  pull  scaler,  with  blade  looking  away  from  handle, 
in  position  on  inoaio  lingual  of  lower  second  molar. 

Fig.  284.     The  15-8-12  scaler  in  position  on  buccal  of  lower  second  mohir. 


Fig.  285. 


Fig.  286. 


Fig.  285.  Plaster  model  of  case  in  wliicli  tlie  tissue  overlying  a  pocket  on  the 
Tnesio-buceal  root  of  an  upper  first  tuhImi  was  cut  away  to  reduce  the  depth  of  the 
pocket  and  facilitate  the  cleaniii<f. 

Fig.  286.  Plastei'  iinidcl  of  a  similar  <'asc  uii  tiic  buccal  side  nf  the  mesial  root 
of  a   lower  first  molar. 


Fig.  2S^ 


Fig    288. 


Fig.  281). 


Fig.  287.  Radio^raj)!!  of  a  case  in  wliifli  an  iiijiny  witli  a  lijjature  had  caused 
the  formation  of  a  ))()ekct  on  the  mesial  si(h"  of  the  ui.i)er  k-ft  central  incisor  and  the 
teeth  had  separated  about  1  mm.  They  were  gradually  drawn  together,  and  the 
appliance  shown  in  the  illustration  was  cemented  in  place  (on  the  lingual)  to  hold 
them  in  contact.  This  was  ii;  October,  1909.  The  radiograph  was  taken  five  years 
later. 

Fig.  288.  Radiograph  of  a  case  in  whicli  the  alveolus  of  a  lower  second  molar 
has  been  almost  entirely  destroyed. 

Fig.  289.  A  panoramic  radiograi)liic  vi.w  of  a  case  of  suppurative  i)ericementitis. 
This  patient,  a  woman  of  forty,  hail  comjilained  for  several  years  of  joint  inflam- 
mation, particidarly  of  the  elbows,  knees  and  ankles.  The  lower  molars  had  all  been 
exti'acted.  The  lower  incisors  and  cuspids  were  in  good  condition,  the  bicuspids  were 
nuH'li   involved. 


Fig.  290. 


Fig.  293. 


FiGS.  290  TO  293.     Plaster  niu.lcls  of  cases  in   wliicli   rcjots  witc  aiiiiKitJitcil. 

P^IG.  290.  Tlip  lingual  root  ol'  lliis  uii|i('r  lirst  molar  was  aiii|iu1ati'il  on  account 
of  a  siippiirativc  pcricfuiciititis.  Tlic  tooth  was  slightly  cloiigatcil  at  thi'  time.  The 
inij)ri'ssion  for  this  inodi'l  was  taken  fifteen  years  ai'ter  the  operation.     The  soft  tissue 


roots    Ncrv    closely 


tlu 


iiitour    is    such    that    it    is   easy    to 


hugs   the    remain  in} 
keep  clean. 

Figs.  291  a\d  292  are  buccal  and  occlii>-al  views  nf  the  same  case.  The  mesio- 
buccal  root  of  this  upper  first  molar  ^\as  ampnt.ited  and  a  gold  crown  placed  on  the 
other  two.     The  soft  tissue  fills  the  sejital  s|iai-e  xcry   perfectly. 

Fig.  293.  A  case  in  which  the  distal  rout  ul'  a  lower  first  molar  was  amputated. 
The  distal  half  of  the  crown  of  th:'  tooth  was  also  cut  away,  and  a  gold  crown  was 
made  to  restore  the  full  occlusal  surface.  The  patient  cleanses  the  open  space  by 
tlushing  it  wilh  a   moidliful  of  water. 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  197 

tissues  and  the  operation  may  proceed  at  once  without  discom- 
fort to  the  patient. 

Care  of  tissues  by  the  dentist.  Wliat  has  been  said  rela- 
tive to  the  care  of  the  gingivae  following  the  removal  of  deposits 
of  serumal  calculus  applies  with  even  greater  force  to  the  tissue 
overlying  pus  pockets.  In  connection  with  the  removal  of  the 
deposits  the  pockets  should  be  thoroughly  irrigated  with  warm 
salt  solution,  to  remove  small  particles  of  deposits  which  may 
not  have  been  brought  away  with  the  scalers.  This  will  also 
cleanse  the  space  of  blood  and  other  debris,  and  leave  the  tissue 
in  the  best  possible  condition.  This  will  be  referred  to  in  the 
discussion  of  the  reasons  for  the  abandonment  of  the  use  of 
antiseptics  in  these  pockets. 

The  patient  should  be  required  to  return  several  times,  if 
necessary,  at  intervals  of  a  few  days  for  irrigation  of  the  pock- 
ets. This  should  be  continued  until  the  inflammation  is  reduced 
and  the  mouth  and  teeth  are  comfortable.  The  patient's  atten- 
tion should  be  called  to  the  technic  of  using  the  syringe  and  he 
should  come  to  feel  the  washing  of  the  pockets  in  order  that  he 
may  know  that  he  is  succeeding  in  the  subsequent  care  of  his 
mouth. 

Care  by  the  patient. 

One  could  hardly  conceive  of  better  care  on  the  part  of  the 
patient  than  the  washing  of  such  pockets  twice  daily,  using  salt 
solution  in  a  rubber  bulb  syringe.  This  is  effective  in  that  the 
space  is  thoroughly  cleaned  without  injury  to  the  soft  tissue. 
The  future  of  such  a  case  depends  very  largely  on  the  care  which 
the  patient  may  be  induced  to  exercise.  Those  who  are  faithful 
may  so  fully  control  conditions  that  little  progress  will  be  made 
in  many  years.  For  all  practical  considerations,  such  cases  are 
well  so  long  as  they  are  kept  clean.  Careful  and  persistent 
washing  will  keep  the  tissues  free  from  irritation  caused  by 
accumulations,  and  all  micro-organisms  which  are  free  in  the 
pocket  will  be  removed  at  each  washing.  Under  this  treatment 
the  progress  of  such  cases  may  be  stayed,  and  the  teeth  may  be 
retained  for  many  years  of  comfortable  service,  without  danger 
to  the  general  health.  Proper  care  by  the  patient  can  not  be 
expected  unless  the  need  of  it  is  explained  and  the  patient's 
interest  is  awakened.  Exact  directions  should  be  given,  and  it 
should  be  urged  that  these  be  carried  out  to  the  most  minute 
detail. 

The  syringe  shown  in  Figure  187  is  the  best  type  for  the 


198  SPECIAL    DENTAL    PATnOLOGY. 

pMtieiit.  The  bulb  fits  well  in  the  hand.  If  the  patient .  is 
instructed  to  hold  the  nozzle  between  the  thumb  and  first  finger 
while  the  bulb  is  pressed  with  the  other  fingers,  he  will  have 
lietter  control  of  the  position  of  the  end  of  the  nozzle.  They 
must  learn  to  hold  it  in  just  the  right  relation  to  the  teeth  and 
the  gingivae,  as  shown  in  Figure  188. 

The  sodium  chloride  tablets,  which  can  be  purchased  at 
almost  every  drug  store,  are  very  convenient  for  this  purpose. 
An  ordinary  drinking-glass  holds  about  eight  ounces  of  water, 
which  requires  two  tablets  to  make  a  physiological  salt  solution. 
(See  Figure  177.) 

In  some  cases  in  which  proximal  surfaces  are  involved  and 
the  septal  tissue  has  receded,  contacts  can  not  be  maintained 
tight  enough  to  prevent  a  little  food  from  passing  occasionally, 
although  this  may  not  become  crowded  very  tightly  upon  the 
septal  tissue.  The  septal  space  will,  however,  fill  up  by  food 
entering  it  from  the  buccal  and  lingual  embrasures,  rather  than 
through  the  contact.  In  this  case  the  food  is  not  packed  very 
tightly  and  does  no  great  hann  if  it  is  regularly  removed  after 
meals. 

Generally  such  impactions  can  be  cleaned  away  by  the 
syringe  alone.  Sometimes  a  toothpick  may  be  necessary  to 
remove  them.  It  is  to  this  class  of  cases  particularly  that  the 
wood  toothpick  is  most  applicable,  for  in  these  there  is  plenty 
of  space  in  which  to  use  the  broad  end  of  the  toothpick  without 
injuring  the  remaining  tissue.  There  are  a  good  many  cases 
occurring  in  elderly  persons  in  which  the  septal  gingivae  are 
practically  gone,  and  the  spaces  between  the  gingival  portions 
of  the  proximal  surfaces  fill  with  food  from  the  embrasures, 
when  there  is  no  leak  between  the  contact  points.  This  is  best 
removed  by  the  wood  toothpick  followed  by  the  jets  of  water 
from  the  syringe.  I  have  seen  cases  of  this  kind  go  on  doing 
good  service  for  many  years  with  this  simple  treatment. 

Subsequent  examinations. 

Patients  should  be  required  to  visit  the  dentist  frequently 
for  examination,  and  for  the  correction  of  any  errors  that  may 
be  found  in  their  own  care.  As  previously  mentioned  for  other 
conditions  a  definite  arrangement  should  be  made  for  the  care 
of  the  case.  It  should  be  understood  that  this  is  necessary  to 
success.  By  such  a  plan,  beginning  pus  pockets  may  be  found 
at  a  very  early  period,  so  that  palliative  treatment  can  be  contin- 
ued against  these  to  the  best  advantage.     The  key  to  all  of  this 


CHRONIC    SUPPURATIVE   PERICEMENTITIS.  199 

palliative  treatment  is  the  holding  in  check  of  suppurative  pro- 
cesses. If  this  be  successfully  done,  the  palliative  treatment  is 
worth  while ;  if  in  any  case  it  is  not  successfully  done,  the  pallia- 
tive treatment  should  be  discontinued,  and  the  teeth  should  be 
removed. 

The    ADMINISTRATION    OF    EMETIN    HYDROCHLORATE. 

In  discussing  the  causes  of  suppurative  pericementitis  I 
have  referred  to  the  discoveries  of  Barrett  and  others  of  the 
endameba  buccalis  in  practically  all  of  these  pockets.  While 
these  findings  have  not  yet  proven  that  these  protozoa  are  the 
cause  of  the  formation  of  the  pockets,  there  seems  to  be  no 
question  but  that  the  use  of  an  endamebacide  results  in  a 
prompt  improvement  in  the  appearance  of  the  overlying  tissues. 
Emetin  hydrochlorate,  an  alkaloid  of  ipecac,  is  administered  for 
this  purpose,  either  by  injection  into  the  pockets,  by  tablets 
taken  by  the  mouth,  or  by  hypodermic  injection  in  the  arm  or 
other  convenient  location  —  one-third  or  one-half  grain  may  Ije 
given  each  day  for  four  or  five  days. 

While  it  now  appears  likely  that  this  very  simple  treatment 
will  be  a  valuable  aid  in  the  management  of  these  cases,  its  use 
must  in  all  probability  be  considered  as  a  palliative  rather  than 
a  curative  measure,  and  its  effect  very  temporary,  as  the  pocket 
will  remain  as  a  harbor  inviting  reinfection.  As  has  been  men- 
tioned, the  investigations  of  the  role  which  the  endamebas  play 
in  this  disease  have  not  yet  progressed  sufficiently  to  justify  an 
extended  report  in  this  book.  This  discussion  is  better  suited 
to  journal  articles  for  some  time.  The  work  which  has  been 
done  is,  however,  one  step  further  in  our  study  of  the  pathology 
of  this  disease. 

Surgical  treatment  of  pockets. 

In  cases  in  wliich  the  pockets  on  labial,  buccal  or  lingual 
surfaces  are  deep,  the  depth  may  be  reduced  by  cutting  away  the 
overlying  tissue,  or,  in  other  words,  by  cutting  away  the  gum 
tissue  that  is  undermined  by  the  disease  of  the  peridental  mem- 
brane. This  should  be  cut  away  as  far,  or  a  little  beyond,  the 
point  to  which  the  disease  has  reached,  which  generally  means 
some  cutting  away  of  the  margin  of  the  alveolar  process  as  well 
as  the  soft  tissue.  In  this  way  the  pocket  can  ])e  eradicated, 
and  in  some  cases  a  fairly  permanent  cure  can  be  effected, 
though  this  is  rare.  (See  Figures  285  and  280.)  A  very  good 
way  of  doing  this  is  with  the  actual  cautery.     If  the  wire  is  white 


200  SPECIAL   DENTAL   PATHOLOGY. 

hot,  it  cuts  very  nicely,  without  causing  much  pain,  and  with 
very  little  hemorrhage.  Many  of  the  cauteries  now  being  sup- 
plied to  dentists  do  not  have  sufficient  current  to  heat  the  wire 
as  hot  as  it  should  be;  therefore  they  cause  unnecessary  pain 
and  do  not  cut  well. 

The  tissue  may  be  cut  away  with  a  knife,  novocain  being 
injected  for  anesthesia.  A  tenaculum  may  be  thrust  through 
the  tissue  into  the  pocket,  and  wliile  holding  with  this,  two  cuts 
should  be  made  parallel  with  the  length  of  the  root  and  one 
connecting  these  at  the  position  of  the  deepest  part  of  the  pocket ; 
or  the  tissue  forming  the  pocket  may  be  held  with  a  pair  of 
pliers  or  tissue  forceps,  one  beak  being  placed  within  the  pocket, 
while  the  cuts  are  made  with  the  knife.  The  tissue  must  be  very 
thoroughly  removed,  and  even  then  it  will  often  grow  over  a 
portion  of  the  denuded  root,  reforming  the  pocket.  The  wound 
should  be  thoroughly  irrigated  until  all  hemorrhage  has  ceased, 
and  no  blood  clot  should  be  allowed  to  remain,  as  it  will  aid  the 
tissues  in  building  across  the  space.  It  will  often  be  necessary 
to  cut  this  away  several  times. 

There  is  considerable  variation  in  results  following  this 
treatment.  In  some  cases  there  will  not  be  much  tendency  to 
the  reforming  of  the  pocket,  or  there  will  remain  a  very  shallow 
pocket  in  place  of  the  former  deep  one.  The  shallow  pocket 
gives  the  patient  the  opportunity  to  do  more  effective  cleaning 
and  the  danger  of  reinfection  is  therefore  very  greatly  reduced. 
In  other  cases  the  tissue  will  regrow,  covering  all  or  nearly  all 
of  the  space  from  which  it  was  cut,  and  little  or  nothing  will 
have  been  accomplished.  The  rule  is,  however,  that  something 
will  be  gained  in  reducing  the  depth  of  the  pocket  each  time  the 
overlying  tissue  is  cut  away. 

This  treatment  is  often  contraindicated  in  the  upper  incisor 
region  on  account  of  the  unsightly  appearance  of  the  denuded 
root.  However,  if  it  becomes  a  question  of  exposing  the  root, 
or  extracting  the  tooth,  the  loss  of  the  tooth  may  be  postponed 
by  cutting  off  the  overlying  tissue. 

There  is  little  hope  for  those  cases  in  which  pockets  of 
considerable  depth  have  formed  on  proximal  surfaces.  It  is 
usually  impractical  to  cut  away  the  interproximal  soft  tissue  to 
eliminate  a  pus  pocket,  as  has  just  been  mentioned  for  buccal 
and  labial  surfaces,  as  there  would  remain  a  pocket  between  the 
teeth  which  would  be  little  better  than  the  previous  pus  pocket. 
Occasionally  cases  present  in  which  several  teeth  in  the  bicuspid 
and  molar  region  have  had  their  membranes  detached  for  about 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  201 

an  equal  distance  on  proximal,  buccal  and  lingual  surfaces. 
If  the  pockets  are  not  very  deep,  the  soft  tissue  may  be  removed 
all  around  such  teeth,  thus  leaving  the  interproximal  spaces  open 
to  the  gingival  of  the  contacts,  the  remaining  interproximal 
tissue  being  on  the  same  level  as  that  on  the  buccal  and  lingual. 
This  gives  the  best  opportunity  for  cleaning. 

Following  such  an  operation,  the  condition  is  similar  to  that 
occasionally  seen  in  the  mouths  of  old  people,  the  gingivae  having 
receded  sufficiently  to  leave  all  of  the  enamel  and  sometimes  a 
little  of  the  cementum  exposed  to  view,  with  a  considerable  open 
space  to  the  gingival  of  each  contact. 

The  use  of  splints. 

In  some  cases  splints  of  various  forms  may  be  used  to 
prevent  tooth  movement.  If  there  is  a  single  pocket  which  has 
progressed  sufficiently  to  cause  the  contact  to  be  opened,  a  splint 
may  be  applied  to  hold  the  two  teeth  firmly  together  and  thus 
prevent  food  impaction  through  the  contact^  and  also  prevent 
the  opening  of  other  contacts.  Two  gold  bands,  soldered 
together,  may  be  cemented  on.  Such  an  appliance  is  particu- 
larly well  adapted  to  lower  incisors.  In  the  bicuspid  and  molar 
region,  two  gold  inlays,  soldered  together  at  the  position  of  the 
normal  contact  of  the  teeth,  may  be  employed.  Or,  in  the  case 
of  the  upper  incisors,  an  appliance  may  be  placed  on  the  lingual 
surfaces,  if  the  bite  will  permit. 

I  show  a  radiograph  (Figure  287)  of  a  case  in  which  a 
pocket  about  three  millimeters  deep  on  the  mesial  surface  of  an 
upper  left  central  incisor,  had  caused  the  teeth  to  separate  about 
one  millimeter.  This  pocket  had  been  caused  by  drawing  a  liga- 
ture too  tightly  about  the  tooth,  cutting  away  the  fibers  on  the 
mesial  surface.  Several  days  were  required  to  bring  the  teeth 
into  contact.  Then  two  holes  were  drilled  into  the  lingual  sur- 
face of  this  tooth  in  the  gingival  third.  A  slot  was  made  in  the 
enamel  connecting  them,  and  an  inlay  was  cast  to  fit  the  slot  and 
holes.  A  single  hole  was  cut  in  the  right  central,  and  a  piece  of 
iridio-platinum  wire,  bent  to  fit  in  this  hole  in  the  right  central, 
was  soldered  to  the  inlay.  The  appliance  was  cemented  to 
place,  holding  the  teeth  in  contact.  This  operation  was  per- 
formed in  October,  1909.  The  pocket  has  received  careful  atten- 
tion since  and  the  depth  has  not  increased  more  than  one  and 
one-half  or  possibly  two  millimeters  in  the  five  years  which 
elapsed  before  the  radiograph  was  made.  The  patient,  a  woman 
of  forty,  has  never  had  a  tooth  extracted  and  there  is  no  other 


21 


202  SPECIAL    DENTAL    PATHOLOGY. 

disease  of  the  investing  tissues  about  her  teeth.     She  is  very 
faithful  in  the  use  of  the  syringe. 

Such  measures  may  be  indicated  in  cases  like  the  one  just 
cited,  but  be  contraindicated  in  others  where  the  pockets  are  no 
deeper.  The  greater  the  number  of  pockets,  the  less  should  we 
think  of  stay  appliances,  and  the  more  of  extraction.  The  diflfi- 
culties  and  dangers  increase  with  the  number  and  depth  of  the 
pockets.  In  those  cases  in  which  there  is  a  more  or  less  general 
involvement  of  the  investing  tissues,  the  value  of  the  teeth  for 
mastication  must  be  weighed  against  the  danger  to  the  general 
health,  and  I  am  inclined  to  advise  radical  rather  than  palliative 
treatment. 

Radical  Treatment. 

When  indicated.  Eadical  treatment  l)y  root  am]iutation 
or  extraction  should  be  employed  in  all  of  those  cases  in  which 
the  teeth  are  not  doing  well  under  palliative  treatment.  In 
cases  in  which  periodic  severe  suppurations  occur,  and  especially 
those  in  which  the  patient  has  a  slight  rise  of  temperature  much 
of  the  time,  or  if  there  is  considerable  soreness  of  the  cervical 
lymphatics,  palliative  treatment  should  be  discontinued.  These 
conditions  should  not  be  allowed  to  continue  because  of  the 
danger  of  systemic  infections.  It  will  be  a  surprise  to  many 
how  quickly  the  cervical  glands,  which  are  sore  when  palpated, 
disappear  or  become  ver\^  small  nodules  which  are  difficult  to 
find,  after  the  teeth  have  been  extracted.  The  entrance  of  infec- 
tion into  the  system  through  the  hTiiphatics  is  stopped  at  once. 

It  is  well  to  keep  a  close  watch  over  the  temperature  of 
these  patients.  If  the  temperature  is  found  to  run  from  99  to 
100  degrees,  it  should  be  taken  as  an  indication  that  a  slight 
toxemia  is  occurring  from  the  absorption  of  the  products  of 
bacteria  which  are  growing  in  the  pus,  or  from  the  pus  which 
is  being  absorbed. 

The  discussion  of  systemic  infections  from  mouth  foci  is 
presented  elsewhere.  What  I  wish  to  urge  here  in  the  manage- 
ment of  cases  is  that  we  should  be  very  certain  that  we  do  not 
allow  general  or  special  infections  of  distant  parts  which  will 
menace  the  general  health  and  life  of  the  patient.  The  applica- 
tion of  radical  treatment  will  put  a  prompt  stop  to  all  of  this, 
for  the  parts  heal  very  readily  indeed  after  operations  of  this 
character.  If  any  single  statement  can  be  made  with  greater 
positiveness  than  all  others,  relative  to  this  disease,  it  is  that 
the  suppurative  condition  is  cured  almost  immediately  with  the 


CHRONIC    SUPPUKATIVE    PERICEMENTITIS.  203 

extraction  of  the  tooth,  so  far  as  each  particular  socket  is 
concerned. 

As  pockets  present  which  are  deeper,  the  difficulties 
increase.  As  soon  as  those  fibers  which  pass  from  tooth  to 
tooth,  or  from  tooth  to  alveolar  process  are  involved,  tooth 
movement  is  apt  to  begin.  This  movement  is  more  serious  when 
the  involvement  is  on  the  lingual  of  the  upper  incisors,  or  on  the 
proximal  surfaces,  particularly  of  the  bicuspids  and  molars; 
In  either  case  the  gradual  movement  and  separation  of  the  teeth, 
which  have  been  described  in  detail,  present  the  greatest  diffi- 
culty in  the  management,  because  the  opening  of  the  contacts 
invites  food  impaction,  which  causes  sufficient  irritation  to  keep 
up  a  low-grade  inflammation,  even  though  the  patient  gives  the 
best  possible  care  by  prompt  and  thorough  cleansing. 

Over  and  over  again  dentists  come  to  me  with  models  of 
protruding  incisor  teeth,  and  ask  my  advice  as  to  moving  them 
back  and  the  possibilities  of  keeping  them  in  place.  Generally, 
I  advise  that  they  be  extracted.  If  this  is  done  in  good  time,  it 
may  save  the  remaining  teeth.  If  only  the  four  incisors  are 
involved,  and  these  are  extracted,  a  bridge  supported  by  the 
cuspid  roots  may  be  placed  with  fair  prospects  that  it  will  do 
good  service.  I  have  followed  this  plan  in  a  considerable  num- 
ber of  cases  in  which  the  curve  of  the  arch  was  not  too  great. 
I  recall  one  case,  in  which  I  did  not  consider  it  wise  to  place  a 
bridge,  because  the  leverage  would  be  too  great  on  the  teeth  to 
which  it  would  be  attached,  and  I  made  a  partial  denture  carry- 
ing the  four  teeth.  This  covered  the  entire  roof  of  the  mouth, 
and  for  many  years  afterward  there  was  no  involvement  of  the 
membranes  about  the  remaining  teeth. 

Radical  treatment,  thou,  means  iliat  eaeli  tooth  tliat  has 
given  rise  to  a  considerable  pus  formation,  which  can  not  be 
controlled  by  palliative  treatment,  should  be  extracted  as  soon 
as  this  fact  has  been  ascertained.  It  should  make  no  difference 
whether  there  are  two  or  three  teeth  together,  or  the  whole  num- 
ber of  teeth  in  the  mouth.  It  is  wrong  from  several  points  of 
view  to  allow  sueli  cases  to  go  on  suppuraliug  year  aftor  year. 
not  only  on  account  of  the  menace  that  such  a  suppuration  is  to 
the  life  of  the  individual,  which  is  enough  in  itself  to  demand  the 
extraction  of  sudi  tcctli,  l)ut  also  from  tlio  fact  tliat  the  contin- 
ued suppuration  until  the  teeth  have  loosened,  cuts  away  so  much 
of  the  alveolar  process,  and  even  of  the  bone  in  which  they  are 
seated,  that  when  the  teeth  are  finally  lost  there  is  practically  no 
residual  alveolar  ridge  on  which  to  place  a  set  of  artificial  teeth 


204  SPECIAL   DENTAL   PATHOLOGY. 

that  may  be  used  with  comfort.  After  watchfulness  for  many- 
years,  I  have  come  to  consider  that  this  is  really  a  veiy  impor- 
tant matter,  and  always  when  suppuration  has  gone  on  until  it 
is  plain  that  no  cure  can  be  had  in  the  case  except  by  radical 
treatment,  the  teeth  should  be  extracted  without  further  delay. 
It  is  very  bad  practice  indeed  to  treat  a  case  until  finally,  when 
the  teeth  have  been  extracted  and  the  mouth  has  healed,  it  is 
found  to  be  impossible  to  make  a  set  of  artificial  teeth  which  may 
be  worn  with  comfort  and  be  satisfactoiy  in  mastication,  because 
of  the  very  scant  residual  alveolar  ridge.  The  patient  is  then 
doomed  to  trouble  for  the  rest  of  his  lifetime,  and  tliis  could  have 
been  prevented  if  the  teeth  had  been  extracted  in  time. 

I  should  not,  however,  continue  very  loose  teeth  in  the  mouth 
under  any  consideration.  When  teeth  have  become  shaky  on 
account  of  the  extensive  parting  of  the  membrane  from  them, 
they  should  certainly  be  extracted  without  delay.  The  fact  that 
some  such  teeth  have  been  known  to  tighten  and  do  service 
should  not  enter  into  practical  consideration,  for  the  cases  have 
too  much  uncertainty  to  enter  into  a  rule  of  practice.  Figure 
288  shows  a  lower  second  molar  which  was  held  to  the  process 
by  but  a  few  fibers  of  the  peridental  membrane  about  the  apex 
of  the  root.  Many  other  illustrations  show  teeth  with  very  little 
attachment  remaining.  In  Figure  261  there  is  hardly  a  tooth 
in  the  entire  denture  which  has  sufficient  attachment  to  hold  it 
securely  in  place. 

Once,  in  visiting  a  dentist  who  was  enthusiastic  in  the  treat- 
ment of  these  diseases,  I  sat  waiting  for  him  to  complete  a 
treatment  of  a  case.  I  knew  the  patient  and  knew  the  condition 
of  his  mouth.  After  the  dentist  was  through,  he  came  into  the 
reception-room  with  this  patient  and  T  talked  with  them  for  a 
few  minutes.  A\nien  the  patient  had  gone  the  dentist  asked  me 
a  question  regarding  the  case  and  I  insisted  that  he  should 
extract  every  tooth  in  the  mouth  without  delay.  He  replied 
that  he  would  cure  the  case  and  I  needn't  be  alarmed.  I  was 
next  reminded  of  this  case  by  the  announcement  in  the  papers 
that  the  man  had  died  of  heart  disease  coming  on  after  an  attack 
of  rheimiatism.  This  man  would  not  have  been  classed  as  a 
very  susceptible  person  to  disease,  but  rather  the  contrary.  He 
had  always  heen  a  robust,  healthy  person.  My  belief  is  that  the 
mouth  infection  was  the  cause  of  his  death. 

I  have  seen  similar  cases  among  patients  whom  I  have 
myself  observed  and  examined,  and  some  who  have  been  under 
my  care.     I  tried  the  treatment  which  I  believed  to  be  best,  as 


CHRONIC    SUPPURATIVE   PERICEMENTITIS.  205 

thoroughly  as  possible,  until  some  of  these  cases  were  lost  by- 
death  occurring  somewhat  suddenly,  as  in  the  case  mentioned. 
Others,  I  think  I  saved  by  the  liberal  use  of  the  forceps,  and 
they  became  healthy  and  vigorous  again. 

Amputation  of  roots. 

The  lingual  root  of  the  upper  first  molar  is  often  hopelessly 
involved  in  disease,  when  no  other  root  in  the  mouth  has  lost  its 
membrane.  The  rule  is  that  this  root  may.  be  cut  away  from 
its  crown,  and  the  tooth  left  standing  upon  the  buccal  roots. 
If  these  are  healthy,  it  may  do  service  for  many  years.  My  own 
experience  in  this  operation  has  been  especially  fortunate,  for 
I  can  recall  no  case  in  which  such  a  tooth  has  not  done  well,  if 
the  disease  was  confined  to  that  one  root.  The  amputation  is 
done  by  cutting  the  root  away  close  against  the  crown  of  the 
tooth,  aiming  to  cut  it  at  the  bifurcation  of  the  roots,  with  a  good 
slope  toward  the  occlusal,  which  will  clean  readily.  The  space 
laid  open  in  this  way  will  often  so  fill  up  with  soft  tissue  that 
no  pocket  will  remain.  Of  course,  before  this  is  cut  away,  the 
pulp  must  be  removed  and  the  root  canal  in  this  particular  root 
should  be  solidly  filled,  preferably  with  gold.  This  may  be  done 
in  a  few  minutes  and  leaves  a  filling  in  the  canal  after  the  root 
is  amputated,  which  may  be  nicely  polished.  Figure  290  is  from 
a  model  made  fifteen  years  after  the  lingual  root  of  an  upper 
first  molar  was  amputated. 

This  operation  may  be  applied  to  any  one  root  of  the  upper 
first  molar.  If  the  mesio-buccal  root  has  a  pocket  on  its  mesial 
surface  which  has  become  so  deep  as  to  be  incurable,  and  in 
which  palliative  treatment  is  not  successful,  it  may  generally  be 
cut  away  after  a  similar  fashion  and  removed.  This  will  end 
the  danger  of  infection  at  once.  Figures  291  and  292  are  of  an 
upper  first  molar,  the  mesio-buccal  root  of  which  was  ampu- 
tated. A  gold  crown  was  placed,  restoring  the  full  occlusal 
surface.  I  have  cut  away  the  disto-buccal  root  a  number  of 
times,  yet  it  is  not  quite  as  easy  of  approach  as  either  of  the 
other  two.  It  is  often  much  depressed  in  between  the  other 
roots  at  its  junction  with  the  crown,  and  this  makes  the  opera- 
tion somewhat  more  complicated.  A  close  study  of  the  case 
beforehand  will  show  the  direction  of  the  cutting  necessary,  and 
it  may  be  accomplished  with  safe-ended  fissure  burs,  insuring 
that  there  will  be  no  cutting  of  other  roots  by  contact  of  the 
end  of  the  instrument.  I  have  in  a  few  cases  cut  away  both 
buccal  roots.     Occasional!}^  a  similar  operation  may  be  done  on 


206  SPECIAL   DENTAL   PATHOLOGY. 

an  upper  second  molar,  although  the  bifurcation  of  the  roots 
is  seldom  low  enough,  and  the  roots  usually  stand  too  close 
together  to  make  it  successful.  In  most  cases,  a  radiograph 
will  show  the  position  of  the  bifurcation  and  the  relation  of  the 
roots.  Or  curved  explorers,  such  as  are  used  in  examinations 
for  proximal  decays,  may  be  passed  alongside  the  root  and 
around  it  at  the  position  of  the  bifurcation. 

Either  the  mesial  or  distal  root  of  a  lower  first  molar  may 
be  similarly  cut  away,  and  the  tooth  will  do  well  with  a  sin- 
gle root.  Sometimes  a  root  of  a  lower  second  molar  may  be 
removed  in  the  same  way.  In  amputating  one  root  of  a  lower 
molar,  I  have  usually  cut  away  the  corresponding  portion  of 
the  crown.  The  cutting  to  separate  the  roots  should  be  entirely 
from  the  root  to  be  removed,  thus  leaving  the  remaining  root 
in  the  best  form  to  receive  a  crown.  Figure  293  is  from  a  model 
of  a  case  in  wliich  the  distal  root  of  a  lower  first  molar  was 
removed.  The  entire  occlusal  surface  was  restored  with  a  gold 
crown,  which  had  been  in  place  nearly  seven  years  when  the 
impression  was  taken. 

Management  of  Cases  of  Chronic  Suppurative  Pericementitis. 
Examination. 

The  determination  of  a  course  of  treatment  for  each  case 
presenting  should  be  based  upon  a  careful  examination  of  the 
teeth,  gingiva',  gums  and  alveohir  processes.  A  visual  exam- 
ination should  first  be  made,  noting  any  points  of  redness  or 
other  signs  of  inflammatory  movement;  also  looking  for  the 
extrusion  of  pus  in  any  position,  and  especially  pus  exuding 
from  between  the  gingivae  and  the  teeth.  Deposits  of  salivary 
calculus  should  ])e  noted,  also  any  other  causes  of  inflammations. 

When  satisfied  with  the  visual  examination,  then  a  more 
close  and  careful  examination  should  be  made  by  palpation  and 
instrumentation.  A  finger  should  be  placed  on  the  gum  on 
either  side  of  the  alveolar  process  and  with  considerable  pres- 
sure gradually  brought  down  onto  the  gingivje,  over  each  tooth, 
beginning  at  some  certain  point  such  as  a  central  incisor,  and 
following  back  tooth  by  tooth  to  the  third  molar,  watching  for 
the  extrusion  of  pus  from  beneath  the  gingivae  while  so  doing. 
Pus  issuing  from  between  the  gingivae  and  the  tooth  is  a  special 
mark  which  should  be  carefully  noted,  whether  it  comes  from 
the  lingual,  from  the  buccal,  or  from  the  proximal  side.  This 
examination  should  include  ever^^  tooth  in  a  regular  order,  often 


CHRONIC    SUPPURATIVE   PERICEMENTITIS.  207 

repeating  the  movement  about  a  certain  tooth  to  be  sure  of  cor- 
rectness. In  doing  this  the  sense  of  touch  should  be  used  very 
carefully  to  detect  any  points  from  which  the  alveolar  process 
may  have  been  absorbed  about  a  particular  tooth.  This  part 
of  the  examination  is  especially  important,  and  eveiy  dentist 
should  carry  himself  through  a  very  severe  training  in  order  to 
become  proficient.  Each  tooth  should  be  tested  as  to  its  firm- 
ness or  looseness  and  inquiry  should  be  made  as  to  the  cause  of 
the  loss  of  missing  teeth. 

An  instrumental  examination  should  next  be  made.  The 
subgingival  explorer  should  be  used;  beginning  in  some  certain 
place,  the  attachment  of  the  gingivae  to  the  tooth  should  be 
explored  in  its  entire  circumference,  so  that  it  may  be  definitely 
known  whether  the  attachments  are  all  perfect,  or  if  there  be 
breaks  and  pockets  along  the  sides  of  the  roots.  If  there  are 
pockets,  the  depth  of  the  pockets  becomes  very  important. 
A  careful  search  should  be  made  for  deposits  of  serumal  cal- 
culus, both  in  subgingival  spaces  and  pus  pockets.  This  may 
be  done  with  the  subgingival  explorers  at  the  same  time  when 
the  line  of  attachment  of  the  peridental  membrane  is  being 
determined,  althougli  in  extensive  cases  a  separate  examination 
should  be  made  for  each  to  insure  greater  accuracy.  In  this 
way,  tooth  by  tooth,  the  whole  mouth  is  examined. 

An  examination  should  be  made  to  determine,  if  possible, 
the  cause  of  each  area  of  inflammation.  In  many  instances  this 
will  include  the  condition  of  the  contacts  and  will  require  that 
they  be  carefully  tested.  The  relationship  between  the  contacts 
and  depth  of  proximal  pockets  is  of  importance  in  determining 
whether  or  not  operations  for  the  restoration  and  maintenance 
of  proper  contacts  would  be  successful. 

A  record  of  the  examination  should  be  made  which  should 
include  every  point  that  is  not  in  health,  and  the  cause,  or  causes, 
if  ascertained.  As  skill  is  ac(iuired  in  making  these  examina- 
tions, they  can  be  done  quite  rapidly,  and  yet  thoroughly. 
A  simple  plan  of  doing  this  will  be  given  under  the  heading  of 
Examinations  of  the  Mouth. 

Radiographs.  The  examination  should  usually  include  a 
number  of  radiographs  —  the  number  depending  on  the  preced- 
ing findings.  If  but  a  single  pocket  is  found,  and  all  the  other 
tissues  are  in  good  health,  a  radiograph  may  not  be  considered 
necessary,  particularly  if  a  local  cause  of  the  pocket  is  evident. 
As  the  nuni1)er  of  areas  of  inflammation  is  hirger,  the  necessity 


208  SPECIAL.  DENTAL  PATHOLOGY. 

for  radiographs  is  increased,  both  for  the  purpose  of  confirming 
the  instrumental  examination,  and  to  show  definitely  the  extent 
of  absorption  of  bone  which  may  have  occurred.  In  all  cases 
in  which  a  considerable  number  of  teeth  are  involved,  the  radio- 
graphs should  include  the  roots  of  every  tooth  in  both  arches. 
One  will  often  be  surprised  in  such  cases  to  find  a  much  more 
extensive  involvement  of  the  alveolar  process  than  is  indicated 
by  careful  examinations  without  radiographs. 

Radiographs  are  necessary  to  a  full  history  of  a  case. 
They  should  be  taken  on  the  small  films  placed  inside  the  mouth. 
This  usually  requires  ten  for  two  full  dentures;  two  on  each 
side  and  one  in  front  for  each  arch.  At  the  present  time,  the 
transparent  (positive)  films  seem  to  give  the  best  results.  They 
are  read  best  by  holding  a  ground  glass  between  the  film  and  a 
light,  although  they  show  nearly  as  well  when  held  toward  a 
window.  Tliicker  films,  which  require  the  making  of  a  print, 
are  less  desirable,  as  the  finer  detail  is  not  so  accurate.  Plates, 
which  include  a  larger  number  of  teeth,  generally  show  insuffi- 
cient detail  to  be  satisfactory. 

If  a  case  of  suppurative  pericementitis  is  found  and 
recorded  by  radiographs  in  this  way,  the  progress  of  the  disease 
may  be  readily  noted  by  taking  additional  radiographs  in  the 
future,  and  comparing  them.  These  radiographs  should  be 
squarely  through  the  interproximal  space,  so  that  a  pocket  on 
the  proximal  surface  will  be  clearly  shown.  If  not  squarely 
through  the  interproximal  space,  the  tooth  itself  may  obscure 
the  pocket.  Sometimes  it  will  be  found  necessary  to  make  two 
radiographs  of  the  front  teeth,  one  for  each  side  of  the  median 
line,  in  order  to  get  the  direction  right  to  show  pockets  on  the 
mesial  or  distal  sides  of  the  roots  of  these  teeth. 

The  best  radiographs  will  show  the  destruction  of  bone  to 
the  labial,  buccal  or  lingual  of  roots,  although  in  many  cases  the 
density  of  the  root  obscures  the  picture.  In  cases  in  which  there 
is  some  doubt  as  to  whether  the  radiograph  shows  the  true  condi- 
tion, a  subgingival  explorer  may  be  passed  to  the  full  depth  of 
the  pocket  and  held  in  position  while  the  radiograph  is  made. 
This  instrument  will  be  shown  through  the  tooth  and  will  indi- 
cate in  the  radiograph  very  accurately  the  depth  of  the  pocket. 

Plan  of  treatment  for  each  case. 

The  treatment  to  be  followed  in  the  particular  case  may  be 
either  preventive,  palliative  or  radical,  or  a  combination  of 
these  methods. 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  209 

Cases  will  vary  from  those  in  which  only  a  few  teeth  are 
slightly  involved,  requiring  palliative  treatment,  to  those  in 
which  the  denture  is  already  so  badly  wrecked  that  immediate 
removal  of  all  teeth  will  be  determined  to  be  the  best  course.  In 
many,  certain  teeth  with  bad  pockets  will  require  radical  treat- 
ment, while  the  effort  will  be  made  to  save  the  remainder.  In 
those  mouths  in  which  palliative  or  radical  treatment  is  indi- 
cated for  a  number  of  teeth,  the  limit  of  care  in  preventive 
treatment  should  be  applied  to  those  teeth  which  have  not  as  yet 
become  involved  in  peridental  disease. 

Nowhere  in  the  practice  of  dentistry  is  there  better  oppor- 
tunity for  the  exercise  of  good  judgment,  based  on  experience 
and  carefully  recorded  observation,  than  in  determining  the 
course  to  be  pursued  in  the  management  of  these  cases.  The 
retention  of  teeth  which  should  be  extracted  often  interferes 
with  the  effectiveness  of  palliative  and  preventive  measures  and 
the  denture  will  be  lost  much  earlier  than  it  would  have  been  had 
such  teeth  been  removed  in  the  beginning.  It  is  especially  urged 
that  a  plan  must  be  determined  upon  by  which  the  particular 
mouth  will  be  kept  free,  or  practically  free,  from  suppuration. 
As  the  care  by  the  patient  is  an  important  part  of  palliative 
treatment,  the  failure  to  interest  and  train  the  patient  will 
mean  that  the  teeth  will  be  lost  much  earlier  than  in  a  similar 
case  in  which  the  fullest  cooperation  of  the  patient  is  secured. 
If  a  case  presents  with  but  one  or  two  bad  pockets  and  there  is 
the  opportunity  to  free  the  mouth  of  disease  by  extracting 
these  teeth,  it  will  often  be  the  best  course  to  pursue. 

In  all  of  tliis,  it  should  be  kept  in  mind  that  the  sooner  the 
teeth  are  removed,  the  better  will  be  the  residual  alveolar  ridge 
for  artificial  dentures.  Therefore,  we  have  to  consider  not  only 
the  present  value  of  the  teeth  in  mastication  and  the  effect  of  the 
mouth  condition  on  the  general  health,  but  also  the  future  possi- 
bilities of  mastication  with  artificial  dentures  in  relation  to  the 
physical  welfare  of  the  patient. 

SENTIMENT  IN  ITS  RELATION  TO  THE  TREATMENT  OF  DISEASES  OF  THE 
PERIDENTAL  MEMBRANE. 

There  is  a  widespread  sentiment  among  the  laity  that  these 
diseases  are  somehow  curable,  and  a  search  is  continually  going 
on  to  find  practitioners  who  can  succeed  in  this.  We  can  not 
treat  this  sentiment  with  contempt;  it  is  well  fixed,  and  we  must 
deal  with  it  as  we  find  it.  The  choice  of  a  course  to  pursue  is 
often  difficult.     We  must  contrive  to  convince  these  patients 

♦ai 


210  SPECIAL.   DENTAL   PATHOLOGY. 

without  using  means  which  are  too  harsh,  and  this  is  a  most 
serious  phase  of  the  situation. 

I  may  refer  to  a  comparatively  recent  case  which  was  sent 
to  me  for  examination  after  the  dentist  had  failed  in  his  effort 
to  control  the  discharge  of  pus.  The  patient,  and  several  den- 
tists who  were  present,  were  evidently  dissatisfied  with  my 
decision  that  the  teeth  should  be  extracted.  I  looked  over  the 
case  a  little  hurriedly,  and  found  such  deep  pockets  about  so 
many  of  the  teeth  that  there  was  no  question  as  to  the  indication 
for  their  removal,  and  I  advised  that  all  of  the  teeth  —  thirty- 
two  of  them  —  be  extracted.  After  I  had  returned  to  my  study, 
one  of  the  demonstrators  came  to  me  and  said  that  there  was  a 
considerable  objection  to  the  carrying  out  of  my  order,  so  I 
immediately  returned  to  the  case.  I  had  previously  said  nothing 
about  having  radiographs  made,  for  the  reason  that  in  my  judg- 
ment it  was  unnecessary.  It  then  occurred  to  me  that  radio- 
graphs were  desirable  in  this  case  from  the  educational  point  of 
view,  and  the  patient  was  at  once  sent  to  the  radiographer  for 
this  purpose.  They  showed  extensive  absorption  of  the  alveo- 
lar process  of  practically  every  tooth.  When  these  were  studied 
by  the  patient  and  by  the  others  who  objected  to  the  removal  of 
the  teeth,  a  complete  change  of  sentiment  occurred  and  the  teeth 
were  extracted.  Many  of  the  teeth,  which  made  such  a  good 
appearance,  had  less  than  a  quarter  of  an  inch  of  bony  alveolar 
process  about  the  ends  of  their  roots,  and  the  incisors  had  but 
one-eighth  inch  of  bony  process  remaining.  We  should  use 
every  means  of  this  kind  to  satisfy  the  sentiment  of  our  patients, 
for  they  should  be  positively  convinced  that  the  treatment  pro- 
posed is  correct,  especially  when  we  have  determined  that  the 
most  radical  treatment  must  be  employed.  It  would  seem  that 
no  further  argument  would  be  necessary  to  convince  a  person 
that  the  teeth  should  be  removed,  if  radiographs  such  as  are 
shown  in  Figures  234  or  261  were  exhibited  and  explained  in 
comparison  with  others  showing  the  normal  condition  of  the 
bone,  yet  some  will,  against  all  advice,  insist  on  retaining  such 
teeth  at  all  hazards. 

The  plan  of  examination  here  given  is  much  more  thorough 
than  that  which  has  generally  prevailed  heretofore.  It  is  essen- 
tial that  such  a  close  and  careful  examination  of  cases  of  this 
kind  be  made.  This  information  is  necessary  as  a  basis  for 
proper  treatment.  It  is  also  necessary  as  a  means  of  so  pre- 
senting the  difficulties  to  patients  as  to  convince  them  that  the 
proposed  treatment  is  right,  in  order  that  they  will  agree  to  have 


CHRONIC    SUPPURATIVE   PERICEMENTITIS.  211 

it  done.  In  a  considerable  percentage  of  cases,  the  rigid  search 
for  information,  and  judicious  care  in  the  presentation  of  the 
evidence,  will  be  required  to  put  aside  this  sentiment  and  give 
the  dentist  an  opportunity  to  apply  the  treatment  best  calcu- 
lated to  benefit  the  patient.  A  plain  and  fair  presentation  of 
the  conditions  found,  and  the  treatment  proposed,  will  usually 
be  best. 

The  widespread  interest  of  the  medical  profession  in  mouth 
infections  in  relation  to  general  health,  and  the  wonderful 
advance  in  popular  knowledge  of  these  things  during  recent 
years,  have  done  much  toward  influencing  the  sentiment  of  our 
people.  This  will  be  of  material  assistance  to  the  intelligent 
dentist  in  the  management  of  his  patients.  It  also  places  upon 
him  a  greater  responsibility,  and  he  should  not  only  make 
the  most  careful  study  of  each  case,  but  critically  observe  the 
progress  of  all  cases,  whenever  the  opportunity  presents,  in 
order  that  his  judgment  may  become  better  and  better  as  time 
passes. 

Abandonment  of  antiseptics  in  the  treatment  Of  suppurative 
pericementitis. 

As  for  other  conditions  and  diseases,  the  pathology  of  which 
has  not  been  understood,  the  treatment  of  suppurative  peri- 
cementitis has  included  a  wide  variety  of  medicaments.  Almost 
every  drug  which  might  be  classed  as  a  caustic,  germicide,  anti- 
septic or  sedative  has  been  used. 

The  first  efforts  to  treat  these  pockets  were  made  at  the 
time  when  the  use  of  antiseptics  in  the  treatment  of  infections 
was  prominently  before  the  medical  profession.  Dentists  there- 
fore undertook  to  control  the  discharge  of  pus  by  the  use  of  the 
various  germicides  and  antiseptics  which  were  available.  Vari- 
ous preparations  of  phenol,  copper  sulphate,  zinc  chloride,  iodin, 
oil  of  cassia,  oil  of  cloves,  many  other  of  the  essential  oils,  and 
similar  drugs  were  commonly  used  for  this  purpose.  Many  of 
these  were  caustic  as  well  as  antiseptic,  and  not  only  destroyed 
the  organisms  within  the  pocket,  but  much  of  the  soft  tissue  as 
well,  and  many  pockets  were  doubtless  made  deeper  by  the  use 
of  such  drugs. 

Clinical  observation  of  the  results  led  the  more  careful  men 
to  gradually  change  from  the  stronger  to  the  milder  antiseptics. 
Laboratory  tests  of  the  potency  of  the  various  antiseptics,  also 
experiments  showing  their  action  on  animal  tissue,  led  to  greater 
and  greater  caution  in  their  use. 


212  SPECIAL,   DENTAL   PATHOLOGY. 

I  remember  the  case  of  a  j^oung  woman  in  whose  month 
there  were  two  very  bad  pus  pockets.  One  of  these  was  on  the 
labial  surface  of  the  root  of  an  upper  lateral  incisor,  and  the 
other  on  the  buccal  surface  of  the  upper  first  bicuspid  on  the 
opposite  side  of  the  mouth.  I  had  her  come  for  treatment  every 
day  for  some  time.  That  was  many  years  ago,  and  I  undertook 
to  stop  the  pus  formation  by  using  a  twenty  per  cent  solution  of 
phenol.  Under  this  treatment  the  case  seemed  to  become  worse 
instead  of  better.  Then  I  tried  ninety-five  per  cent  phenol,  using 
it  very  cautiously  by  wrapping  a  few  fibers  of  cotton  on  a  point 
and  carrying  that  up  under  the  free  gingivae  into  the  pocket, 
being  as  careful  as  possible  about  injury  to  healthy  tissue. 
With  this  the  pus  became  less,  but  the  pockets  did  not  heal.  Then 
1  left  off  the  treatment  for  a  time,  and  the  discharge  became 
worse  again.  Then  I  tried  pretty  much  everything  in  my  medi- 
cine case  —  iodin,  zinc  chlorid,  oil  of  cassia,  and  various  other 
poisons  to  micro-organisms  and  to  healthy  tissue.  It  was  of  no 
avail.  Again  I  allowed  the  case  to  rest  without  treatment.  The 
pockets  seemed  to  do  better,  but  pus  appeared  on  pressure  over 
the  roots  of  the  teeth.  I  threatened  to  remove  the  soft  tissue 
covering  together  with  all  of  the  diseased  part,  but  the  patient 
showed  the  teeth  and  gums  very  prominently,  and  this  would, 
especially  in  the  case  of  the  lateral  incisor,  make  a  permanent 
blemish  which  would  be  almost  as  bad  as  the  loss  of  the  tooth. 
It  was  not  done.  Some  years  later  both  teeth  were  lost.  In  this 
mouth  no  other  teeth  were  attacked.  The  teeth  and  gingivae 
remained  healthy  while  I  knew  her. 

A  similar  case  occurred  a  number  of  years  afterward  in 
which  only  an  upper  lateral  incisor  was  affected.  This  case  was 
treated  by  simply  washing  with  water  in  which  two  or  three 
drops  of  oil  of  cloves  were  shaken  in  a  quarter  of  a  tumblerful. 
The  labial  gingiva?  dropped  down,  forming  a  notch  in  the  crest 
line,  but  there  was  no  further  discharge.  This  case  healed,  not 
by  a  reattachment  of  the  soft  tissue  to  the  cementum,  but  by  the 
reduction  in  depth  of  the  pocket  as  a  result  of  the  recession  of 
the  gingiva.  Such  cases  are  not  very  frequent,  but  I  have  had 
enough  of  them  to  make  an  interesting  group.  In  more  recent 
years  the  pockets  in  such  locations  which  were  shallow  when  I 
found  them,  got  well  under  careful  washing  with  water  or  salt 
solution.  There  was  generally  a  deformity  of  the  crest  line  of 
the  gingivjp  after  healing,  marking  the  spot.  The  deeper  ones 
did  not  get  well. 

It  should  now  be  recognized  that  practically  every  drug 


CHRONIC   SUPPURATIVE   PERICEMENTITIS.  213 

that  we  have  used  in  these  pockets  for  the  purpose  of  destroying 
the  micro-organisms  has,  in  the  long  run,  done  more  harm  than 
good.  Many  have  been  successful  in  that  they  have  destroyed 
the  micro-organisms  which  were  in  the  pocket,  and  also  in  that 
they  relieved  the  pain,  so  that  cases  were  apparently  improved. 
We  know  now,  however,  that  the  drugs  which  destroyed  the 
micro-organisms  were  also  injurious  to  the  tissues  with  whicli 
they  came  in  contact;  that  the  relief  from  pain  was  often  due 
to  the  anesthetic  effect  of  the  drug;  that  the  resistance  of  these 
tissues  was  so  weakened  by  the  drug  that  they  could  not  for 
days,  possibly,  exercise  their  normal  defensive  activity;  that 
they  were  therefore  unable  to  meet  new  infections  as  aggres- 
sively as  before ;  that  cases,  under  such  treatment,  very  gradu- 
ally went  from  bad  to  worse  as  a  result  of  infections. 

Defense  by  the  tissues. 

To-day  the  indication  is  not  so  much  for  a  drug  which  will 
destroy  the  micro-organisms,  but  rather  to  mechanically  remove 
the  bulk  of  these  and  keep  the  tissues  in  such  condition  that  they 
will  exercise  their  defensive  powers  to  the  utmost.  This  is  best 
accomplished  by  a  method  of  cleaning  which  will  free  the  pocket 
of  all  organisms  that  may  be  washed  out  without  interfering 
with  the  normal  aggressiveness  of  the  tissue  cells;  so  that  the 
tissues  may  have  the  best  opportunity  to  destroy  the  organisms 
which  have  entered  them. 

The  defense  by  the  tissues  themselves  should  be  reckoned 
with  in  any  treatment  of  suppuration.  This  is  especially  true 
when  the  suppuration  occurs  in  the  mouth.  Under  the  condi- 
tions found  in  the  mouth  it  is  impossible  to  prevent  reinfection, 
because  of  the  abundance  of  the  saliva,  and  its  constant  state  of 
infection.  Such  a  thing  as  actual  surgical  cleanliness  can  not  be 
maintained.  If  the  use  of  antiseptics  upon  the  soft  tissues  of 
the  mouth  reduces  the  normal  defense  set  up  by  the  tissues 
themselves,  and  my  personal  observation,  as  related,  teaches  me 
that  they  do,  they  should  not  be  used  upon  these  soft  tissues 
when  these  are  suffering  from  injury  or  disease.  Here  any 
injury  to  this  normal  defense  in  the  treatment  is  a  wrong  of 
such  importance  that  its  consideration  can  not  be  omitted.  Other 
forms  of  treatment  must  be  adopted  that  will  be  free  from  this 
objection. 

Treatment  by  cleanliness. 

Treatment  by  cleanliness  means  treatment  by  methodical 
irrigation  of  the  wound  with  sterile  water,  or  with  phyciological 


214  SPECIAL   DENTAL,   PATHOLOGY. 

salt  solution.  In  all  such  cases  there  is  more  or  less  fluid  — 
serum  or  pus,  or  both  —  containing  micro-organisms,  and  the 
neighboring  soft  tissue  is  attacked  by  these  organisms,  which 
penetrate  within  it  to  variable  depths.  The  thorough  irrigation 
of  such  an  infected  wound  or  cavity  removes  at  once  the  bulk  of 
the  organisms  and  other  material  which  are  injurious  to  the 
tissues.  If  plain  water  or  salt  solution  is  used  for  this  purpose, 
there  is  no  interference  with  the  most  aggressive  action  of  the 
tissue  in  attacking  those  organisms  which  have  entered  it.  On 
the  other  hand,  if  a  strong  antiseptic  is  used,  the  cavity  can  not 
be  more  effectively  freed  of  its  fluid  contents  than  with  water, 
and  the  medicament  will,  to  a  greater  or  less  degree,  inhibit  the 
normal  defense  of  the  tissue. 

The  statement  of  the  case  may  be  put  in  this  form.  If  one 
can  prevent  the  accumulation  of  micro-organisms  upon  the  tis- 
sues or  in  pockets  about  the  teeth,  where  there  is  the  constant 
tendency  to  reinfection,  the  tissue  cells  will  be  kept  in  a  more 
normal  state  of  activity,  and  will  be  able  to  resist  the  micro- 
organisms already  in  the  tissues  by  vigorous  phagocytic  action. 
If  the  tissue  cells  are  not  weakened  by  macerating  solutions,  or 
poisoned  by  antiseptics,  and  a  high  degree  of  cleanliness  is  main- 
tained, other  things  being  equal,  the  quicker  will  the  organisms 
which  have  entered  the  tissues  be  destroyed.  It  is  for  this  rea- 
son that  the  frequent  washing  of  pockets  with  physiological  salt 
solution  should  be  substituted  for  the  periodical  application  of 
antiseptics.  If  patients  can  be  trained  to  effectivelj^  wash  out 
these  pockets  two  or  three  times  daily,  as  a  part  of  their  habitual 
routine  cleaning,  this  would  seem  to  be,  and  in  years  of  trial  has 
l)roven,  the  very  best  plan  of  treatment. 

The  use  of  physiological  salt  solution  is  recommended  for 
all  open  wounds  in  preference  to  plain  water,  because  no  osmosis 
occurs  and  pain  is  thus  avoided.  If  an  open  wound  is  flooded 
with  sterile  water,  more  or  less  pain  is  caused ;  on  the  other  hand, 
if  the  irrigating  fluid  is  of  a  higher  speciflc  gravity  —  contains 
more  salts  than  the  tissues,  pain  will  result.  The  solution 
should  be  one  that  will  not  materially  disturb  the  balance  of 
osmosis  between  itself  and  the  tissues  in  either  direction.  A 
solution  of  .6  of  one  per  cent  to  .9  of  one  per  cent  will  be  very 
satisfactory.  Such  a  solution  may  be  conveniently  made  by 
adding  a  teaspoonful  of  table  salt  to  a  pint  of  water  and  steril- 
izing, or  by  the  use  of  the  speciall}^  prepared  sodium  chloride 
tablets  in  sterile  water. 

Perhaps  one  of  the  strongest  illustrations  of  this  will  be 


CHRONIC    SUPPURATIVE    PERICEMENTITIS.  215 

found  in  placing  water  in  tlie  eye.  Pure  water  will  be  painful 
to  the  eye.  A  properly  gaged  salt  solution  will  not  be  painful, 
and  the  eye  may  be  washed  in  all  of  its  parts  and  will  continue 
to  feel  comfortable.  If  the  salt  is  excessive  in  the  solution,  again 
the  eye  will  be  painful.  Therefore  it  is  the  balance  of  the  specific 
gravity  of  the  salt  solution  with  the  blood  serum  and  the  sermn 
in  the  tissues,  that  is  necessary  for  painless  irrigation.  If  the 
solution  used  is  at  the  body  tempera,ture,  this  will  be  a  further 
aid  in  the  same  direction. 

This  treatment  is  exactly  in  line  with  that  employed  by 
many  surgeons  of  to-day  in  the  treatment  of  infected  wounds. 
Our  use  of  medicaments  in  the  treatment  of  these  pockets  has 
all  along  followed  more  or  less  closely  the  use  of  similar  germi- 
cides and  antiseptics  by  physicians  and  surgeons  in  the  treat- 
ment of  infections  elsewhere.  The  time  has  arrived  when  we 
should  abandon  the  use  of  drugs  of  this  kind  for  the  purposes 
which  have  been  mentioned. 

The  following  quotation  from  L.  R.  G.  Crandon's  work  on 
''Surgical  After-Treatment"  is  perhaps  as  fair  a  statement  of 
the  present  position  of  our  most  progressive  surgeons  in  regard 
to  the  use  of  antiseptics : 

"The  attempt  to  destroy  all  the  bacteria  in  the  focus  by 
means  of  antiseptics  is  futile.  That  it  has  been  a  failure  is 
attested  by  the  fact  that  for  the  last  few  years  the  practice  has 
gradually  gravitated  toward  the  use  of  extremely  mild  anti- 
septics for  surgical  dressings,  soaks,  and  irrigation,  such  as 
weak  boric  acid,  chlorinated  soda,  or  normal  salt  solution.  If 
the  antiseptic  solution  is  sufficiently  strong  to  kill  the  bacteria, 
it  will  be  equally  efficient  in  its  injury  to  tissue  cells.  Further, 
excepting  in  unusual  cases,  the  antiseptic  application  can  not 
be  expected  to  come  into  contact  with  all  the  bacteria.  Those 
which  have  escaped  its  action  will  find  a  good  culture  medium 
for  further  growth  in  the  cells  that  have  been  injured,  and  in 
the  exudation  which  the  irritation  of  the  antiseptic  will  have 
produced.  Gauze  drains  have  their  part  in  making  matters 
worse,  when  they  obstruct  the  discharge  and  lead  to  the  accu- 
mulation of  pus  and  bacteria  under  some  slight  pressure. 

"The  persistence  of  infectious  disease  in  spite  of  surgical 
effort  attests  in  such  cases  surgical  failure.  Extirpation  that 
does  not  completely  extirpate,  drainage  that  does  not  effectually 
drain,  and  impossible  methods  of  destroying  bacteria  in  the 
infected  foci,  should  not  be  expected  to  lead  to  any  but  a  con- 
siderable percentage  of  failures,  and  suggests  the  advantage  of 


216  SPECIAL   DENTAL    PATHOLOGY. 

methods  that  will  be  more  effectual  in  the  accomplishment  of 
cure  than  those  in  present  use  in  the  treatment  of  localized 
infections." 

As  a  proper  basis  for  this  change,  we  have  only  to  review 
the  history  of  the  use  of  antiseptics  in  surgical  operations.  Such 
a  review,  if  given  in  detail,  would  require  a  book  in  itself.  I 
shall,  therefore,  in  the  following  pages  give  an  outline  of  the 
more  important  events,  to  which  will  be  appended  a  list  of  the 
principal  facts  and  discoveries  along  this  line  during  the  past 
one  hundred  years. 


ANTISEPTIC    AND    ASEPTIC    SURGEKY.  217 


THE   DEVELOPMENT   OF  ANTISEPTIC  AND 

ASEPTIC  SURGERY  AND  THE  USE 

OF  ANTISEPTICS. 

ILLUSTRATIONS:    FIGURES  294-295. 

As  one  reviews  the  development  of  modern  surgery,  there 
would  seem  to  be  a  natural  division  into  three  principal  periods. 
The  first  may  be  called  the  preparatory  period,  during  which  a 
number  of  isolated  facts  were  discovered,  which  were  later 
brought  together  to  substantiate  the  principle  of  the  bacteriology 
of  infection.  The  second  should  be  called  the  antiseptic  period, 
during  which  the  dominant  idea  was  the  employment  of  anti- 
septics to  combat  and  destroy  pathogenic  organisms.  The  third 
should  be  called  the  aseptic  period,  during  which  the  principal 
effort  was  to  prevent  and  combat  infections  by  aseptic  methods. 
If,  however,  one  endeavors  to  actually  separate  the  steps  of 
progress  into  these  three  periods,  it  will  be  found  quite  impos- 
sible to  do  so.  It  will  then  be  recognized  that  the  development 
has  been  very  gradual,  yet  continuous,  without  sharp  divisions, 
from  the  original  announcements  of  Lister  in  1867,  to  the  present 
day.  In  fact,  many  discoveries  previous  to  the  time  of  Lister 
were  necessary  to  this  development,  and  some  of  these  formed 
the  foundation  for  the  work  of  Lister  and  those  who  followed 
him. 

Preparatory  period. 

The  perfecting  of  the  achromatic  microscope  by  J.  J.  Lister 
in  1830  made  possible  the  description  of  epithelial  tissue  in 
animals  by  Henle  in  1837,  and  of  plant  cells  by  Schleiden  in 
1838.  These  were  preliminary  to  the  development  of  Schwann's 
cell  theory  in  1839.  Holmes  pointed  out  the  contagiousness  of 
puerperal  fever  in  1843  and  Semmelweiss  discovered  its  cause 
in  1847.  Cohn  pointed  out  the  vegetable  nature*  of  bacteria  in 
1853,  and  Pasteur's  investigations  of  the  chemical  ]iroducts  of 
putrefaction  in  1856,  led  up  to  the  discovery  that  bacteria  were 
the  cause  of  putrefaction.  The  publication  by  Virchow  in  1858 
gave  to  the  world  a  new  understanding  of  the  cellular  structure 

•Recently  Vaughn  (.Toumal  American  Medical  Association,  Aufrnst  1,  1014)  and 
Kossel  have  shown  "  that  bacteria  contained  no  cellulose  and  are  particulate,  unshielded 
proteins,  and  consequently  more  nearly  related  to  low  forms  of  animal  life."  While 
Vaughn  says  he  would  not  classify  bacteria  as  either  plants  or  animals,  in  their  life 
processes  they  are  more  closely  related  to  animal  life. 


218  SPECIAL.   DENTAL   PATHOLOGY. 

of  animals  and  plants,  and  of  the  nature  of  disease  processes. 
A  little  later,  in  1860,  Lernaire  pointed  out  the  antiseptic  prop- 
erties of  carbolic  acid  (phenol).  Pasteur  had  shown  in  1861  that 
the  fermentations  were  caused  by  micro-organisms  and  had  put 
the  evidence  of  this  in  more  definite  shape  in  1866.  In  the  mean- 
time Lister  had  become  profoundly  impressed  with  the  com- 
municability  of  erysi]ielas,  gangrene  and  septicemia,  and  had 
arrived  at  the  conclusion  that  if  micro-organisms  were  the  cause 
of  fermentations  occurring  outside  the  body,  as  had  been  demon- 
strated by  Pasteur,  these  communicable  diseases  might  be  the 
result  of  fermentations  in  the  body  tissues.  He  also  reasoned 
that,  if  he  could  prevent  the  entrance  of  micro-organisms  into 
the  tissues,  or  destroy  those  that  had  entered,  he  could  prevent 
or  cure  the  diseases. 

Antiseptic  period. 

When  Lister  reported  in  1867  his  wonderful  experiments 
of  the  preceding  years  in  operating  under  a  spray  of  phenol  and 
the  securing,  in  cases  of  deliberate  surgery,  of  wounds  free  from 
infection,  which  healed  without  pus,  his  announcement  of  these 
facts  shook  the  very  foundations  of  the  old-time  surgeiy.  At 
that  time  suppuration  was  considered  to  be  a  necessary  part  of 
the  healing  in  all  considerable  wounds.  Lister  had  followed  the 
controversy  between  Baron  Leibig,  the  great  German  chemist, 
and  M.  Louis  Pasteur,  the  French  chemist,  in  which  Pasteur 
proved  step  by  step  that  fermentation  in  wines,  vinegars  and 
other  fluids  was  not  due  to  a  chemical  change  produced  by 
''molecular  motion,"  as  contended  by  Leibig,  but  was  due  to  the 
growth  in  such  fluids  of  minute  organisms  or  germs.  In  making 
this  proof  the  chemist  Pasteur  developed  a  new  and  revolu- 
tionary science  —  the  science  of  bacteriology  —  and  became  the 
first  and  the  greatest  bacteriologist.  Lister  followed  this  proof 
of  the  role  of  germs  in  producing  fermentation  and  concluded 
that  germs  probably  played  a  similar  role  in  the  body  in  pro- 
ducing septicemia  and  other  surgical  diseases.  What  Lister 
really  thought  to  do  was  to  prevent,  if  possible,  the  decomposi- 
tion of  pus  in  operative  wounds.  For  it  was  to  this,  and  not  to 
laudable  pus  —  as  a  clean,  pure  pus  was  then  called  —  that  sur- 
gical fever,  which  was  destroying  the  lives  of  so  many  surgical 
patients,  was  attributed.  The  prevention  of  pus  formation  had 
not  had  a  place  in  his  thought.  The  result  was  as  much  a  sur- 
prise to  Lister  as  to  others. 

While  to  Lister  is  undoubtedly  due  the  credit  for  develop- 


ANTISEPTIC    AND    ASEPTIC    SURGEKY.  219 

ing  antiseptic  surgeiy,  it  should  be  recognized  that  he  under- 
took this  study  as  a  result  of  the  work  of  Pasteur,  as  is  shown 
by  the  following  quotation  from  a  paper*  by  Lister  in  1873. 
**The  philosophical  investigations  of  Pasteur  long  since  made 
me  a  convert  to  the  germ  theory,  and  it  was  on  the  basis  of  that 
theory  that  I  founded  the  antiseptic  treatment  of  wounds  in 
surgery. ' ' 

Thus  antiseptic  surgeiy  was  born,  and  from  1867  to  this 
date  the  belief  in  the  truth  of  Lister's  deductions  and  the 
development  of  methods  for  perfecting  details  for  efficiency  have 
never  ceased.  No  sooner  had  the  fundamental  discoveries  of 
Pasteur  and  their  practical  application  to  surgery  by  Lister 
begun  to  be  accepted  by  the  profession  than  hundreds  of  men 
in  every  country  took  up  investigations  which  supplemented 
and  expanded  the  new  science  and  art  of  surgery.  Abbe  intro- 
duced the  oil  immersion  lens  in  1872.  Methods  of  staining 
bacteria  were  perfected  by  Weigert  in  1871,  by  Ehrlich  in  1874, 
by  Koch  in  1876,  and  many  others,  thus  preparing  the  way  for 
the  isolation  and  recognition  of  the  various  pathogenic  bacteria. 
In  the  meantime  the  antiseptic  properties  of  numerous  drugs 
were  demonstrated.  This  was  accomplished  by  application  of 
the  antiseptics  to  wounds  to  destroy  micro-organisms  that  had 
entered  them,  which  was  followed  by  methods  of  dressing, 
devised  to  prevent  the  re-entrance  of  micro-organisms  into  these 
wounds  during  the  healing  process.  The  antiseptics  were  also 
used  to  prevent  infection  of  food  and  water  in  sanitation  and  in 
hygiene. 

Lister's  first  experiments  consisted  of  the  employment  of 
assistants  who  stood  near  by  and  kept  the  atmosphere  and 
everything  in  contact  with  the  wound  sprayed  with  a  phenol 
solution,  using  hand  atomizers  for  the  purpose.  From  this 
beginning,  every  conceivable  form  of  experiment  was  tried.  As 
these  studies  progressed,  it  was  found  that  the  formation  of 
pus  was  caused  by  the  ingress  of  certain  micro-organisms,  com- 
prising only  a  few  species,  which  seemed  to  be  common  through- 
out the  world,  and  were  called  pyogenic  organisms,  that  is,  pus 
producers.  Pasteur  isolated  the  streptococci  and  staphylococci 
in  1880. 

Strong    antiseptics,    principallj''    phenol    solutions    in    the 

*  "A  Contribution  to  the  Germ  Theory  of  Putrefaction  and  Other  Fermentative 
Changes,  and  to  the  Natural  History  of  Torulse  and  Bacteria."  A  communication 
to  the  Royal  Society  of  Edinburgh  in  1873,  published  in  the  Transiictions  of  the  Royal 
Society  of  Edinburgh,  1875. 


220  SPECIAL   DENTAL    PATHOLOGY. 

beginning,  were  used  to  antisepticize  everything  wliich  niiglit 
come  in  contact  with  the  field  of  operation.  After  a  time  it  was 
learned  that  the  spray  of  phenol  was  unnecessary  because  other 
antiseptic  precautions  proved  sufficient.  However,  for  probal)ly 
fully  twenty  years  after  Lister's  report  in  1867  the  view  among 
physicians  and  surgeons  that  micro-organisms  from  the  air 
infected  wounds,  was  quite  general.  The  sponges  of  earlier  days 
were  discarded  for  cotton  rolls  and  gauze,  which  could  be  made 
safe  b)^  antiseptics.  Instruments  were  immersed  in  antiseptics, 
the  tissues  within  the  field  of  operation  were  saturated  with 
antiseptics;  the  hands  of  the  operator  and  his  assistants  were 
scrubbed  and  then  bathed  with  antiseptics,  many  operators 
immersing  their  hands  in  two  or  more  different  solutions.  All 
wounds  were  irrigated  with  antiseptic  solutions.  This  was  what 
has  come  to  be  known  as  the  antiseptic  period  in  surgery. 

One  of  my  professional  associates,  Dr.  David  Prince,  visited 
Lister's  clinic  as  well  as  other  clinics  in  Europe,  and  on  return- 
ing to  Jacksonville,  Illinois,  equipped  an  operating-room  with 
an  elaborate  system  of  fans,  sprays  and  filters  ''for  securing  an 
aseptic  operating-room."  I  have  had  reproduced  an  illustration 
of  this  operating-room,  taken  from  a  paper  entitled:  "The 
Relation  of  Micro-organisms  to  Aseptic  Surgery,"  by  Carl  E. 
Black,  M.D.,  published  in  1887.  A  brief  description  accom- 
panies the  illustration.     (See  Eigure  294.) 

Aseptic  period. 

As  the  facts  regarding  infected  wounds  became  established, 
it  opened  the  way  to  the  recogTiition  of  sterile  wounds  as  some- 
thing distinct  from  infected  wounds,  and  led  to  the  treatment  of 
these  by  methods  of  dressing  that  would  exclude  micro-organisms 
during  treatment,  which  was  demonstrated  to  be  sufficient.  This 
was  the  beginning  of  the  aseptic  period.  In  deliberate  opera- 
tions, aseptic  methods  gradually  replaced  antiseptic  methods. 
After  a  time  it  came  to  be  realized  that  a  deliberate  operation 
might  be  performed  under  such  perfect  conditions  of  asepsis 
that  from  the  beginning  of  the  operation  until  the  wound  was 
entirely  healed,  the  tissues  could  be  kept  practically  free  from 
micro-organisms,  and  when  this  could  be  done  antiseptics  were 
unnecessary.  This  came  to  be  known  as  surgical  cleanliness, 
which  means  freedom  from  micro-organisms. 

Use  of  antiseptics  gradually  lessened. 

Very  gradually  the  ideas  of  the  medical  world  have  been 
changing  and  leading  away  from  the  use  of  antiseptics  on  the 


ANTISEPTIC    AND    ASEPTIC    SURGERY.  221 

soft  tissues  in  the  treatment  of  infected  wounds,  because  the 
development  of  more  perfect  cleanliness  pointed  to  a  better  way. 
The  application  of  the  principles  of  surgical  cleanliness  to 
infected  wounds  is  leading  to  the  gradual  abandonment  of  the 
use  of  antiseptics  in  contact  with  the  tissues. 

The  first  idea  of  an  antiseptic  was  that  of  a  drug  which 
would  destroy  micro-organisms,  but  would  not  injure  the  animal 
cell.  The  search  for  such  a  drug  failed.  The  next  idea  of  an 
antiseptic  was  that  of  a  drug  which  would  stop  the  growth  of 
micro-organisms  without  very  material  injury  to  the  animal  cell. 
Many  drugs  are  used  to-day  with  the  idea  that  they  will  do  this. 
This  is  an  error.  It  seems  that  such  a  drug  does  not  exist  to-day. 
There  are  drugs  which  will  temporarily  stop  the  growth  of  micro- 
organisms without  actually  destroying  the  animal  tissue,  but 
they  inhibit,  or  tend  to  inhibit,  the  activit>^  of  the  animal  cells, 
and  the  repair  of  the  wound  is  delayed  for  a  time.  This  has 
been  well  tried  out,  both  on  animals  and  human  subjects. 

One  of  the  greatest  disappointments  in  Dr.  Koch's  life  was 
his  failure  to  cure  tuberculosis  by  the  use  of  antiseptics.  He 
could  sterilize  the  cages  of  his  animals  and  give  them  clean  food, 
and  prevent  them  from  taking  tuberculosis,  but  if  one  took  the 
disease  through  any  mismanagement,  or  was  purposely  infected, 
he  could  not  cure  it.  The  greatest  disappointment  in  the  life 
of  Dr.  Miller  occurred  after  he  had  determined  the  cause  of 
decay  of  dentin.  He  fondly  hoped  to  prevent  caries  by  finding 
an  antiseptic  with  which  he  could  sterilize  the  human  mouth.  In 
this  he  failed.  He  could  not  sterilize  his  own  mouth  for  a  single 
hour  with  any  drug  which  he  could  use.  He  could  greatly  reduce 
the  number  of  organisms  in  his  saliva  by  careful  washing  with 
drugs,  or  with  plain  water,  but  in  a  few  hours  they  would  be  as 
plentiful  as  ever.  I  have  done  similar  experimental  work,  and 
met  with  the  same  disappointments. 

Chemotaxis  and  phagocytosis. 

There  are  some  theories  hinging  around  chemotaxis,  posi- 
tive and  negative,  which  serve  to  explain  what  really  happens, 
whether  the  theories  are  correct  or  not.  Certain  micro- 
organisms are  picked  up  and  destroyed  by  the  phagocytes.  I 
have  seen  and  studied  the  cells  at  this  work,  resupphdng  the 
examples  as  the  first  became  still,  watching  them  for  hours  at  a 
time  on  the  warmed  stage  of  the  microscope  in  inflamed  tissue 
now  and  then  clipped  for  the  puryjose.  The  phagocytes  will 
approach  and  pick  up  certain  micro-organisms.     Other  certain 

22 


222  SPECIAL   DENTAL   PATHOLOGY. 

micro-organisms  they  will  rmi  away  from.  In  the  one  case  we 
have  chemical  conditions  which  bring  the  phagocytes  into  the 
field  —  positive  chemotaxis.  In  the  other  case  the  micro- 
organisms produce  chemical  compounds  which  cause  the  phago- 
cytes to  run  away  —  negative  chemotaxis. 

Metchnikoff  and  some  of  his  brilliant  pupils  at  the  Pasteur 
Institute  in  Paris  developed  the  study  of  phagocytosis.  He 
divided  phagocytes  into  "macrophages"  or  ''fixed  phagocytes" 
and  ' '  microphages  "  or  "  wandering  phagocytes. ' '  Macrophages 
include  large  lympocytes,  myelocytes,  giant  cells  and  other  cells 
which  do  not  form  a  distinct  group,  but  are  known  by  the  size 
of  the  cells  and  seem  to  have  the  function  of  digesting  tissue 
which  is  moribund  or  dead.  On  the  other  hand  the  "micro- 
phages," which  are  "practically  identical  with  the  neutrophile 
and  eosinophile  polymorphonuclear  leucocytes,  have  the  function 
of  taking  up  bacteria  and  digesting  them  —  bacterial  phago- 
cytosis. ' ' 

Conditions  similar  to  chemotaxis  may  be  produced  by  the 
action  of  drugs.  Most  antiseptics  induce  a  negative  chemotaxis 
which  drives  the  phagocytes  out  of  the  field  until  the  effect  has 
passed.  During  this  time  the  healing  process  and  the  formation 
of  pus  will  be  suspended.  Both  will  be  renewed  as  the  drug- 
disappears  from  the  tissue. 

It  should  be  borne  in  mind  that  Vaughn  and  others  have 
proved  that  all  cells  in  the  body,  no  matter  of  what  tissue,  have 
the  power  to  take  food  (protein)  from  the  blood  and  lymph 
streams.  Sometimes,  especially  in  the  jDresence  of  disease  — 
"an  inflammatory  process  from  infection  and  the  efforts  at 
repair"  —  the  cells  take  up  food  which  is  injurious  to  them. 
In  fact  such  cell  injury  is  disease. 

Personal  studies. 

Soon  after  the  publication  of  Lister's  reports,  I  became 
interested  in  this  whole  field  of  investigation.  I  soon  had  a 
very  complete  laboratory  equipment  and  was  making  cultures 
and  studying  the  various  micro-organisms  at  first  hand  from  all 
kinds  of  abscesses,  carbuncles  and  suppurating  wounds,  so  that 
I  became  quite  familiar  with  them.  I  watched  surgeons  closely, 
saw  much  of  surgical  cases,  and  did  some  operating  myself.  I 
read  a  number  of  papers  before  medical  and  dental  societies, 
and  in  1884  published  a  small  book  entitled  "The  Formation  of 
Poisons  by  Micro-organisms."  Subsequently  I  made  extensive 
studies  of  the  potency  of  the  various  antiseptics  in  use  by  sur- 


Fig.  294. 


Fig.  294.  Surgical  oporating  room  equipped  hy  Dr.  David  Prince,  Jacksonville, 
111.,  in  1887.  The  following  description  is  quoted  from  the  article  by  Dr.  Carl  E. 
Black,  referred  to  in  the  text: 

"  The  room  is  a  separate  building  connected  with  the  hospital  building  by  a 
porch.  All  the  air  admitted  to  the  operating  room  above  comes  from  the  basement 
thoroughly  washed.  The  air  passes  into  the  basement  at  2,  through  a  steam  jet  .'?. 
into  a  chamber  where  siilphur  is  constantly  burning,  4.  It  then  passes  under  a  muslin 
diaphragm  6,  through  sprays  of  cold  water  7,  into  a  second  chamber  which  is 
warmed  by  a  stove  9.  It  next  passes  between  a  series  of  muslin  diaphragms  11,  12. 
which  are  kept  dripping  with  cold  water  from  a  rosette  13,  and  is  then  in  the 
operating  room.  Ventilation  is  effected  through  a  flue  14.  Thus  all  the  air  entering 
this  room  is  thoroughly  sterilized  and  the  operation  is  carried  on  in  an  aseptic 
atmosphere.  This  room  contains  only  such  things  as  are  necessary  during  operations. 
There  are  no  closets,  and  the  lioors,  besides  being  of  several  layers,  one  of  which 
is  tarred  paper,  is  filled  with  paraffin.  A  north  light  is  secured  through  a  window 
18,  and  a  skylight  19." 

*22 


Fig.  295. 


Fig.  2do.  Eadiogniph  taken  in  ]!tl4  of  tlio  elbow  of  avni  injured  by  sliotgun  in 
1878.  The  treatment  of  this  arm  by  keeping  it  immersed  in  a  phenol  solution  bath 
for  six  weeks  is  described  in  the  text.  There  was  no  infection,  neither  was  there  any 
formation  of  granulations,  while  the  arm  was  immersed.  The  action  of  the  antiseptic 
on  both  the  micro-organisms  and  animal  tissue  was  well  demonstrated  by  this  case. 


ANTISEPTIC    AND    ASEPTIC    SUEGERY.  223 

geons,  physicians  and  dentists,  and  the  effect  of  these  on  animal 
tissue.  In  1886  and  1887  I  gave  a  series  of  lectures  and  demon- 
strations on  this  work  before  the  Illinois  State  Dental  Society.* 
My  ovens  have  been  in  practically  continuous  oi)eration  up  to 
the  present  time.  In  the  consideration  of  the  use  of  drugs  in  the 
treatment  of  the  dental  pulp,  reference  is  made  to  a  very  inter- 
esting report  of  an  investigation  into  the  effect  upon  animal 
tissue  of  the  various  antiseptics  used  in  dentistry,  made  in  my 
laboratory  by  Dr.  A.  H.  Peck  in  1897.  There  is  also  a  brief 
report  of  recent  similar  experiments,  some  of  which  are  illus- 
trated in  Figures  347  to  358. 

It  was  laboratory  work  of  this  kind,  by  many  men  in  the 
medical  and  dental  professions,  which,  together  with  clinical 
observations  and  practical  surgical  demonstrations,  led  to  the 
changes  in  the  use  of  antiseptics  which  have  been  mentioned. 

One  of  the  most  marked  experiments  showing  the  effect  of 
carefully  used  phenol  upon  the  animal  tissue  occurred  under  my 
personal  observation  and  management.  This  was  in  1878,  when 
there  was  a  flush  of  excitement  over  some  reports  of  advantage 
in  keeping  wounds  immersed  in  water  with  very  moderate  use 
of  antiseptics  during  the  earlier  part  of  the  treatment. 

A  boy  of  fourteen,  while  hunting,  accidentally  discharged 
his  shotgun  in  getting  over  a  fence.  The  charge  struck  the  ulna 
of  the  right  arm  two  inches  above  the  wrist,  went  through  it 
diagonally,  and  left  it  al^out  two  inches  below  the  elbow  joint. 
Examination  for  shot  and  finding  many  in  the  tissues  about  the 
elbow,  indicated  that  there  were  enough  shot  in  the  joint  to 
destroy  its  usefulness.  The  radius  was  uninjured,  the  radial 
artery  was  in  good  condition  and  the  circulation  in  the  hand  was 
good.  The  hand  would  live  and  might  be  valuable  if  that  terrific 
wound  could  be  managed.  The  whole  of  the  ulna  between  the 
points  named  was  gone,  and  much  of  the  soft  tissue  was  shot 
away.  The  wound  lay  wide  open  for  the  whole  distance.  An 
apparatus  that  answered  the  purpose  of  holding  the  tempera- 
ture of  the  water  verj^  close  to  the  body  temperature  and  kept 
it  in  continuous  circulation,  was  quickly  made  and  installed. 
This  included  a  pan,  or  trough,  in  which  the  arm  could  be  laid 
and  swung  above  the  bottom  of  the  pan.  The  wounded  arm  was 
laid  in  it  within  three  hours  after  the  injury.  The  entire  wound 
was  submerged.  The  tissues  were  formed  up  a  bit,  but  they 
were  not  brought  together.    All  parts  could  be  inspected  and  a 

*  Transactions  of  the  Illinois  State  Dental  Society,  1886,  p.  180;    1887,  p.  162, 
22b 


224  SPECIAL   DENTAL    PATHOLOGY. 

syringe  could  be  used  for  extra  washing  of  any  particular  parts. 
At  first  five  per  cent  of  phenol  was  added  to  the  water.  It  soon 
became  evident  that  this  was  too  much,  and  it  was  reduced  to 
two  per  cent.  The  boy  soon  became  comfortable,  or  as  nearly 
so  as  his  confined  position  would  permit.  He  found  ways  to 
make  some  change  in  position  without  disturbing  the  arm.  He 
settled  down  for  a  long  wait  in  bed,  seemed  comfortable,  made 
no  complaint  of  pain,  spent  much  time  in  reading,  was  fond  of 
seeing  visitors  and  talking  with  his  friends  who  called.  Indeed 
this  feature  of  the  case  was  very  remarkable. 

At  the  end  of  a  month  no  progress  toward  healing  could  be 
observed  in  the  wound.  Not  a  single  point  of  granulation  had 
been  seen.  The  boy  seemed  perfectly  well  in  every  other  way. 
Under  these  conditions  the  treatment  was  continued  two  weeks 
longer.  Still  there  was  absolutely  no  healing.  Then  the  arm 
was  removed  from  the  bath  and  placed  in  dry  dressings,  no 
more  antiseptics  were  used.  The  case  was  carefully  watched. 
It  was  two  weeks  longer  before  the  first  appearance  of  granula- 
tion occurred.  After  that  other  points  of  granulation  showed 
themselves  here  and  there,  growing  very  slowly  at  first,  but 
increasing  in  vigor,  and  an  encrustment  of  the  tissues  of  the 
wound  which  had  occurred  in  the  bath,  began  to  be  shed  away. 
Then  the  forming  up  of  the  tissues  that  remained  was  begun  by 
the  use  of  bandages.  They  were  gradually  drawn  together  day 
by  day,  to  bring  the  remaining  portion  of  the  arm  into  the  best 
shape  possible,  and  to  reduce  the  final  area  of  cicatrization  to 
the  narrowest  limits  by  bringing  the  skin  that  remained  as 
closely  around  it  as  we  could.  Under  this  treatment  and  great 
care  in  maintaining  aseptic  conditions,  the  wound  went  on  to 
cicatrization.  The  X-ray  picture  of  the  arm  exhibited  here  was 
taken  about  thirty  years  after  the  accident  and  shows  the  shot 
still  imbedded  in  the  tissues  about  the  elbow.     (See  Figure  295.) 

I  regard  this  case  as  the  best  representation  of  what  anti- 
septics will  do  in  delaying  tissue  growth  in  the  healing  process 
that  I  have  ever  witnessed.  The  surgeon,  Dr.  David  Prince,  was 
with  me  in  the  treatment  of  the  case  from  the  beginning  to  the 
end,  and  was  intensely  interested  in  every  part  of  it.  While  the 
effort  was  to  do  the  best  thing  possible  for  the  boy,  the  whole 
case  was  also  a  study  of  the  healing  process  under  extremely 
difficult  conditions,  and  especially  of  the  effect  of  the  antiseptic 
in  delaying  the  growth  of  granulations,  and  generally  delaying 
the  normal  healing  processes.  In  this  it  is  a  good  type  of  the 
effect  of  the  antiseptics  as  a  class,  tried  out  to  the  ultimate  limit. 


ANTISEPTIC    AND    ASEPTIC    SURGERY.  225 


CHRONOLOGICAL  LIST  OF  PRINCIPAL  EVENTS  IN 

THE  DEVELOPMENT  OF  ANTISEPTIC 

AND  ASEPTIC  SURGERY 

PREPARED  BY  CARL  E.  BLACK,  M.D.,  JACKSONVILLE,   ILL. 

1822.  Pasteur  born. 

1827.  Lister  born. 

1830.  J.  J.  Lister  perfected  achromatic  microscope. 

1831.  Liebig  and  others  discovered  chloroform. 

1831.  Hueter  first  used  chlorine  water  and  creosote  as  disin- 

fectants. 

1832.  Liebig  discovered  chloral. 

1836.  Schwann  discovered  pepsin. 

1837.  Gerhard  differentiated  typhoid  and  typhus   (clinically). 
Henle  described  epithelial  tissue. 

1838.  Schleiden  described  plant  cells. 

1839.  Schwann  published  treatise  on  cell  theory. 
Purkinje  first  used  term  protoplasm. 

1842.  Long  first  used  ether  as  anesthetic. 

1843.  Holmes   first   pointed   out  contagiousness   of  puerperal 

fever. 

1844.  Wells  discovered  nitrous  oxid  as  anesthetic. 

1845.  Ijangenbeck  detected  actinomyces. 

1847.     Semmelweis  discovered  cause  of  puerperal  fever. 

Pasteur  proved  that  fermentation  was  caused  by  micro- 
organisms. 

1850-53.     Cohn  declared  animal  and  vegetable  protoplasm  iden- 
tical. 

1853.  Cohn  demonstrated  vegetable  nature  of  bacteria. 

1854.  Schroder  and  van  Dusch  proved  efficiency  of  cotton  plugs 

for  test-tubes  and  flasks. 
1856.     Panum  investigated  chemical  products  of  putrefaction. 

1858.  Virchow  published  *'Cellularpathologie." 

1859.  Darwin's  Origin  of  Species  published. 

Bataille  i:>roposed  use  of  alcohol  to  i)i'omoto  the  healing 
of  wounds. 


226  SPECIAL   DENTAL   PATHOLOGY. 

1860.  Lemaire  pointed  out  antiseptic  properties   of  carbolic 

acid. 

1861.  Pasteur  discovered  anaerobic  bacteria. 
1863.     Pasteur  investigated  silkworm  disease. 

1865.  Villemin  demonstrated  infectiousness  of  tuberculosis. 

1867.  Lister  introduced  antiseptic  surgery. 

1871.  Weigert  stained  bacteria  with  carmine.  i 

1872.  Abbe  introduced  oil  immersion  lenses. 

1873.  Obermeier  discovered  spirillum  of  relapsing  fever. 

1874.  Ehrlich  introduced   dried  blood  smears   and   improved 

staining  methods. 
Hansen  isolated  bacteria  of  leprosy. 

1875.  Landois  discovered  hemolysis  from  transfusion  of  alien 

blood. 

Losch  observed  parasitic  amebaj  in  dysentery. 

Lister  reasoned  that  pus  formation  was  caused  by  micro- 
organisms. 

Thiersch  proposed  use  of  salicylic  acid  as  an  antiseptic. 

Landois  discovered  that  animal  serum  will  hemolyze 
human  serum. 

1876.  Koch  grew  anthrax  bacilli  on  artificial  media. 
Bollinger  discovered  actinomycosis  in  cattle. 

1877.  Pasteur  discovered  bacillus  of  malignant  edema. 

Von  Bergman  introduced  corrosive  sublimate  antisepsis. 
vl878.     Koch  discovered  causes  of  traumatic  infections. 

Pasteur    discovered    micro-organisms    of    surgical    and 

puerperal  infections. 
Israel  (1845  von  Langenbeck)  discovered  actinomycosis 

in  man. 

1879.  Neisser  discovered  gonococcus. 

Manson  proved  mosquito  vector  of  filaria  sanguinis 
hominis. 

1880.  Pasteur  isolated  streptococcus  and  staphylococcus. 
Ponfick  proved  identity  of  human  and  animal  actinomy- 
cosis. 

Baelz  discovered  parasitic  hemoptysis. 

Pasteur  established  bacterial  cause  of  lobar  pneumonia. 

1880.  Eberth  isolated  typhoid  bacillus. 

\  Mosetig  Moorhof  introduced  iodin  in  surgery. 

1881.  Laveran  discovered  parasite  of  malarial  fever. 
Medin  discovered  epidemic  nature  of  poliomyelitis. 
Koch  introduced  plate  cultures. 


ANTISEPTIC    AND    ASEPTIC    SURGERY.  227 

Finlay  first  suspected  mosquitoes  to  be  carriers  of  yellow 

fever. 
Reed,  Carroll,  Argamonte  and  Lazear  proved  mosquito 

to  be  intermediate  host  in  yellow  fever. 

1882.  Koch  discovered  tubercle  bacillus. 
LoeflQer  discovered  bacillus  of  glanders. 
Walther  Fleming  investigated  cell  division. 

1883.  Klebs  (Edwin)  and  Loeffler  discovered  diphtheria  bacil- 

lus. 
Fehleisen  isolated  micro-organism  of  erysipelas. 
Pasteur  vaccinated  against  anthrax. 
King  first  suggested  that  mosquito  was  intermediate  host 

and  sole  source  of  infection  in  malaria. 
Uuna  introduced  ichthyol. 

1884.  Koch  discovered  cholera  bacillus. 
Nicolaier  discovered  tetanus  bacillus. 

Finkler  and  Prior  established  bacterial  cause  of  cholera 

nostras. 
Crede  introduced  silver  nitrate  instillations  for  infantile 

conjunctivitis. 

1885.  AVeismann  published  memoirs  on  continuity  of  the  germ 

plasm. 
Marchiafava  and  Celli  describe  hemocytozoa. 

1886.  Escherich  discovered  bacillus  coli. 

Von  Bergman  introduced  steam  sterilization  in  surgery. 
Loeffler  established  bacterial  cause  of  swine  erysipelas. 
Soxhlet  introduced  sterilized  milk  for  nutrition  of  infants. 

1887.  Clark  discovered  bacillus  of  Malta  fever. 
Weichselbaum  discovered  meningococcus. 

1887.  Bruce  established  bacterial  cause  of  Malta  fever. 

1888.  Institute  Pasteur  founded. 

Roux  and  Yersin  investigated  the  toxins  of  diphtheria. 

Nuttall  discovered  the  bactericidal  powers  of  blood- 
serum. 

Breiger  first  isolated  toxins. 

Gamaleia  established  bacterial  cause  of  fibrinous  pneu- 
monia. 

1889.  Buchner  discovered  alexins  (protective  bodies). 
Behring  discovered  antitoxins. 

Smith  discovered  parasite  of  Texas  fever. 

Buchner  discovered  bactericidal   effect  of  blood-serum. 

1890.  Imperial  Institute  of  Experimental  Medicine  founded  at 

St.  Petersburg. 


228  SPECIAL    DENTAL   PATHOLOGY. 

Behring  treated  diphtheria  with  antitoxin. 
Koch  introduced  tuberculin. 

1891.  Institute  for  Infectious  Diseases  opened  at  Berlin  under 

Koch. 
Lister    Institute    for    Preventive    Medicine     (London) 
founded. 

1892.  Pfeiffer  discovered  bacterium  of  influenza. 

Welch  and  Nuttall  discovered  bacillus  a^rogenes. 

]\Iaragliaiio,  (1901)  Landsteimer,  (1901)  Eisenberg,  dis- 
covered that  serum  of  diseased  and  even  normal 
donors  will  hemolyze  alien  blood. 

1893.  Smith  and  Kilbourne  demonstrate  transmission  of  para- 

sitic diseases  by  arthropoda. 
Gilbert  discovered  paracolon  and  paratyphoid  bacilli. 

1894.  Kitasato  and  Yersin  discovered  plague  bacillus. 

1895.  Pfeiffer  discovered  bacteriolysis. 

1896.  Max  Gruber  and  Widal  discovered  bacterial  agglutina- 

tion. 
Widal    and    Sicard    introduced    agglutination    test    for 

typhoid  fever. 
Gilchrist  discovered  blastomycosis. 

1897.  Shiga  discovered  dysentery  bacillus. 
Bordet  discovered  bacterial  hemolysis. 

1898.  Loeffler  and  Frosch  investigated  filterable  viruses. 
Looss  demonstrated  transmission  of  hookworm  infection. 
Theobald  Smith  differentiated  between  bovine  and  human 

tubercle  bacilli. 

Nocard  &  Roux  established  bacterial  cause  of  bovine  peri- 
pneumonia. 

Schenck  discovered  sporo-trichosis. 

1899.  Reed  and  Carroll  established  transmission  of  yellow  fever 

by  mosquitoes. 

1900.  Widal  and  Ravant  introduced  cytodianosis. 

1901.  DeVries  stated  mutation  theory. 

Button  and  Ford  discovered  parasite  of  sleeping  sickness. 

1902.  Firth  and  Horrocks  showed  that  flies  could  carry  typhoid 

bacilli. 

1903.  Metchnikoff  inoculated  higher  apes  with  syphilis. 
Bruce  showed  sleeping  sickness  to  be  transmissible  by 

tsetse  fly. 


ANTISEPTIC    AND    ASEPTIC    SURGERY.  229 

Richet,  (1906)  Kosenau  and  Anderson,  (1907)  von  Pir- 
quet  investigated  Anaphylaxis  which  was  discovered 
by  (1798)  Jenner  and  (1839)  Magendie. 
1905.     Schaudinn  discovered  parasite  of  syphilis. 

Bordet   and   Gengou   discovered   bacillus    of   whooping- 
cough, 
1907.     Wasserman  introduced  sero-diagnosis  of  syphilis. 

Von  Pirquet  introduced  cutaneous  reaction  in  tubercu- 
losis. 

1909.  Ehrlich  introduced  salvarsan. 

Hunter  introduced  the  term  "Oral  Sepsis." 
Nogouchi  improved  the  Wasserman  reaction. 

1910.  Henri  and  others  introduced  ultraviolet  sterilization  of 

water. 
Flexner  produced  poliomyelitis  experimentally. 

1911.  Nogouchi  introduced  luetin  reaction. 

Peytron  Rous  transmitted  sarcoma  by  means  of  a  filter- 
able virus. 

1912.  Bass  cultivated  malarial  Plasmodium  in  vitro. 

1913'.     Abderhalden  introduced  ferment  reaction  for  diagnosis 
of  pregnancy  and  dementia  praecox. 
Vaughn  and  Kossel  showed  bacteria  contained  no  cellu- 
lose and  are  more  nearly  related  to  animal  than  vege- 
table life. 


230  speciaTj  dental,  pathology. 


ACUTE  ULCEROUS  GINGIVITIS 

ILLUSTRATION:    FIGURE  29C. 

A  disease  which  I  have  noted  as  occurring  rather  infre- 
quently has  been  described  by  Dr.  Thomas  L.  Gilmer  as  Acute 
Ulcerous  Gingivitis  —  a  term  which  seems  to  me  to  be  apt.  This 
form  of  gingivitis  stands  entirely  apart  from  the  diseases  of 
the  gingiv£e  and  peridental  membrane  which  have  been  described. 
For  this  reason,  the  description  of  it  was  not  placed  with  the 
other  forms  of  gingivitis,  in  order  that  confusion  might  be 
avoided.  Although  I  had  seen  the  disease  previously,  I  had  not 
written  anything  regarding  it  for  publication,  and  Dr.  Gilmer's 
description*  is  the  first  that  I  remember  to  have  seen.  It  is  so 
accurate  a  description  that  I  quote  it  here  in  full. 

''Acute  ulcerous  gingivitis  is  a  disease  seen  but  rarely 
and  has  not,  so  far  as  I  am  able  to  discover,  been  previously 
described.  The  onset  of  the  disease  is  sudden,  the  earliest 
symptoms  indicated  by  a  slight  malaise  which  is  quickly  followed 
by  rapid  ulceration,  at  first  confined  to  the  gingivae,  usually  about 
two  or  three  of  the  anterior  teeth  on  both  jaws  simultaneously 
and  in  corresponding  localities ;  later  it  is  extended  to  the  gums 
about  a  number  of  the  teeth,  or  groups  of  teeth,  but  rarely  if 
ever  does  it  include  the  entire  gum  margin.  The  lingual  mar- 
gins and  festoons  of  the  gums  do  not  participate  at  first  in  the 
•  inflammatory  processes,  but  later  the  festoons  are  destroyed 
and  deep  pockets  are  formed  in  the  interproximal  spaces.  Still 
later  the  lingual  gingivae  participate,  but  in  no  case  have  I  seen 
ulcerous  manifestations  in  this  locality.  In  twenty-four  hours 
after  the  patient's  attention  has  been  called  to  the  condition  of 
his  gums,  the  parts  attacked  present  the  appearance  of  having 
been  gnawed  away  until  most  of  the  gum  tissue  overlying  the 
alveolar  process  immediately  adjoining  the  teeth  has  been 
destroyed.  The  part  of  the  gum  attacked  has  soft,  thickened, 
and  in  some  instances  everted  margins.  The  eroded  parts  form 
pockets  which  are  filled  in  with  a  grayish  pasty  mass,  similar  to 
that  found  in  syphilitic  ulcers  in  the  mouth.  When  this  mass 
is  removed  a  granulation  surface  is  exposed  which  bleeds  easily 
and  is  very  painful  to  the  touch.     The  mucosa  for  a  short  dis- 

•  Dental  Review,  Vol.  20,  1906,  p.  459. 


ACUTE    ULCEROUS    GINGIVITIS.  231 

tance  from  the  ulcerative  margins  is  of  a  dark  red  hue  as  a 
result  of  the  congestion.  The  gum  covering  the  cervical  and 
interproximal  surfaces  of  the  teeth  is  destroyed  sufficiently  in 
some  cases  to  uncover  the  teeth  down  to  the  alveolar  border. 

"The  breath  of  the  patient  is  fetid,  the  saliva  ropy  and  in 
excess  of  the  normal.  The  temperature  in  the  early  stages  of 
the  disease  ranges  about  101  degrees.  The  patient  is  nervous 
and  anxious,  the  appetite  is  poor,  sleep  is  disturbed,  the  bowels 
are  constipated.  Bloody  saliva  escapes  from  the  mouth  during 
sleep,  staining  the  pillow. 

"Without  treatment  the  ulceration  does  not  appear  to 
extend  beyond  the  gingival  border  of  the  gums,  nor  deeper  than 
the  alveolar  process,  but  when  the  case  is  neglected  the  entire 
mucosa  of  the  mouth  in  a  degree  participates  in  the  disease,  that 
is,  to  the  extent  of  becoming  red  and  tender.  The  ulceration 
seems  to  be  limited  to  the  areas  indicated,  and  after  the  destruc- 
tion of  the  mature  tissue  has  ceased,  the  granulations  only 
appear  to  be  destroyed,  leaving  the  pasty  mass  covering. 

"The  submaxillary  lyinphatics  become  involved  early  in  the 
disease.  Microscopically  no  pus  is  observed,  but  the  microscope 
shows  pus  cells  in  abundance. 

"It  is  not  necessarily  a  disease  of  the  poor,  or  those  of 
impaired  vitality.  It  is  not  confined  to  those  who  are  careless 
of  oral  hygiene;  neither  is  it  traceable  to  metallic  poisons, 
syphilis  or  renal  disease. 

"With  treatment,  consisting  of  local  applications  of  anti- 
septic washes  only,  the  disease  yields  slowly,  extending  over  a 
period  of  two  weeks  or  more. 

"After  having  treated  a  few  cases  by  local  antiseptic  appli- 
cations only,  and  finding  the  obstinacy  of  the  disease  to  such 
treatment,  and  knowing  how  sensitive  the  gums  are  to  mercury, 
I  concluded  to  try  its  effect  by  giving  small  doses  of  calomel  in 
combination  with  the  local  treatment,  witli  the  most  happy 
results.  The  home  treatment  consists  of  taking  four  tablets  of 
mercurous  chloride,  4/20  grain  each,  morning,  noon  and  night, 
followed  by  a  saline  cathartic  on  rising.  The  gums  are  thor- 
oughly cleansed  before  breakfast  by  a  swab  of  cotton  dipped  in 
three  per  cent  pyrozone.  Every  two  hours  during  the  day  the 
mouth  is  flushed  with  a  warm  saturated  solution  of  boric  acid, 
to  which  is  added  one  drop  of  the  oil  of  cassia  to  two  ounces  of 
the  solution.  The  office  treatment  consists  in  a  thorough  clean- 
ing of  the  parts  in  the  afternoon  with  three  per  cent  pyrozone, 
followed  by  the  application  of  compound  tincture  of  benzoin. 


232  SPECIAL   DENTAL    PATHOLOGY. 

On  the  third  day  under  this  treatment  a  marked  improvement 
has  uniformly  been  observed,  and  in  a  few  days  more  the  gums 
have  been  fully  restored.  In  the  place  of  the  benzoin,  dilute 
tincture  of  iodine  may  be  substituted  with  equally  good  results. 

**I  have  twice  attempted  through  cultures  to  discover  a 
specific  organism  to  which  the  disease  might  be  attributed,  but 
without  success.  When  another  case  presents  further  search 
will  be  made  for  the  cause." 

The  cases  I  have  observed  have  been  substantially  like  those 
described  by  Dr.  Gilmer;  some  have  been  much  worse,  not  only 
destroying  the  gingivae  to  the  margins  of  the  alveolar  process, 
but  uncovering  the  alveolar  process  and  producing  exfoliation 
of  it  from  the  roots  of  the  teeth  for  nearly  half  their  length. 
Some  of  the  cases  have  been  much  milder  and  have  produced 
only  the  sloughing  of  the  free  gingivae.  They  have  all  been 
attended  with  the  general  symptoms  described  by  Dr.  Gilmer, 
and  in  some  of  them  the  swelling  of  the  lymphatics  about  the 
neck  was  very  great,  but  so  far  as  I  remember,  none  of  these 
suppurated. 

It  is  not  characterized  by  large  amounts  of  pus,  but  there 
is  a  pasty  mass  that  seems  to  confine  and  cover  over  the  micro- 
organisms which  appear  to  be  instrumental  in  causing  the  dis- 
ease. Like  Dr.  Gilmer,  I  have  searched  for  the  specific  micro- 
organism, but  also  like  him,  I  have  failed  to  discover  such. 

Most  of  my  cases  have  been  seen  in  persons  of  mature  age, 
but  a  quite  notable  one  occurred  in  a  child  about  nine  years  old. 
This  case  was  brought  in  to  me  by  a  dentist.  It  was  a  severe 
case,  the  sloughing  occurring  both  in  the  upper  and  lower  jaws 
in  the  positions  mentioned  by  Dr.  Gilmer. 

The  first  of  these  cases  which  presented  to  me  was  treated 
with  local  antiseptics  after  a  somewhat  vigorous  saline  cathartic. 
With  this  treatment  I  have  had  the  same  results  as  described  by 
Dr.  Gilmer.  After  studying  some  of  these  cases  and  especially 
the  characteristic  viscid  covering  which  overspread  the  diseased 
area,  I  decided  to  try  another  method.  I  used  salt  solution  only 
and  persisted  in  the  washing  until  I  had  thoroughly  cleaned  the 
tissues  of  everything  that  could  be  washed  away.  This  is  no 
easy  task,  and  it  is  rather  painful  to  the  patient,  for  it  requires 
considerable  force  in  the  current  of  water  thrown.  I  have  taken 
the  ordinary  two-ounce  rubber  bulb  syringe  and  have  thrown 
the  entire  contents  against  the  tissues  witli  all  the  ])ower  that  the 
grip  of  my  hand  could  bring  to  bear.    It  has  sometimes  required 


ACUTE    ULCEROUS   GINGIVITIS.  233 

four  or  five  syringefuls  to  clean  the  parts;  but  when  once  so 
cleaned,  recovery  has  been  rapid. 

A  few  years  ago  I  had  a  patient,  quite  a  large,  husky  man, 
who  was  referred  to  me  by  his  dentist.  The  case  was  in  an 
early  stage;  loss  of  tissue  by  sloughing  had  not  yet  begun,  but 
was  imminent.  He  was  nervous,  so  much  so  that  I  doubted 
whether  I  would  be  able  to  wash  the  tissues  as  thoroughly  as  I 
desired.  I  told  him  the  treatment  would  be  painful  and  used 
the  syringe  with  sufficient  force  to  stretch  the  tissues  away  from 
the  teeth,  and  removed  every  particle  of  the  pasty  material. 
Afterward  I  told  him  that  I  should  not  hurt  him  so  badly  again, 
and  used  several  syringefuls  of  water  with  less  force,  until  I 
had  the  whole  surface  entirely  clean.  A  saline  cathartic  was 
prescribed.  This  case  received  two  additional  washings  and  the 
inflammation  gradually  subsided.  On  the  second  day  the  fever 
had  abated  to  very  nearly  normal.  The  case  was  well  at  the  end 
of  the  fourth  day.  This  is  perhaps  the  most  rapid  recovery 
that  I  have  observed. 

In  the  case  of  the  child  previously  mentioned,  sloughing 
had  already  occurred,  exposing  the  teeth  down  to  the  margin  of 
the  alveolar  process  in  both  the  upper  and  lower  jaws.  The 
treatment  of  this  was  the  same  as  that  just  described  above, 
except  that  the  force  of  the  stream  was  moderated  on  account 
of  the  pain  caused  by  it.  The  weaker  force  of  the  stream  was 
compensated  by  the  persistence  of  its  application,  and  finally 
the  granulations  were  laid  bare  at  every  point. 

It  will  be  seen  that  this  treatment  was  on  the  supposition 
that  if  we  could  remove  the  micro-organisms  that  were  growing 
in  the  pasty  mass  upon  the  surface,  and  prevent  the  continuous 
reinfection  of  the  tissues,  the  phagocytes  would  quickly  take 
care  of  the  micro-organisms  already  in  the  tissue.  To  facilitate 
the  action  of  the  phagocytes  it  is  necessary  to  keep  the  tissues 
in  very  good  active  condition,  and  it  seems  to  have  been  success- 
ful, not  only  in  the  cases  here  reported,  but  also  in  several 
others. 

I  have  treated  but  five  cases  by  this  method,  all  of  which 
have  done  well.  This  number  of  cases  is  not  sufficient,  however, 
to  fully  establish  the  efficacy  of  the  treatment. 

A  model  of  one  case  is  shown  in  Figure  296.  The  tissues 
were  too  much  inflamed  to  permit  of  an  impression  being  taken 
until  after  the  most  acute  stage  had  passed,  and  the  illustration 
falls  far  short  of  conveving  a  good  idea  of  the  condition.    The 


234  SPECIAL   DENTAL    PATHOLOGY. 

tissues  appear  to  be  much  too  smooth,  and  there  is  no  showing 
of  the  angr\^  character  of  the  inflammation.  It  does,  however, 
give  some  idea  of  the  extent  to  which  the  gingivae  were  destroyed. 
In  manv  cases  the  destruction  is^much  more  extensive. 


Fig.  296. 


Fig.  296.  i'histor  iiuxicl  of  a  case  of  aciito  ulcprons  ginjjivitis,  takiMi  after  the 
case  began  to  show  iiiiproveinenl.  This  illustration  does  not  give  a  good  idea  of  the 
raggedness  of  the  gingiva,  nor  of  the  very  angry  appearance.  It  docs,  however, 
show  something  of  the  extent  to  which  the  tissue  was  destroyed. 


■^^=C: 


"■    h      c 


d 


e 

Fig.  297. 


Fig.  298. 


Fig  297.  Margin  of  the  dental  pulp:  a,  a.  Dentinal  fibrils,  P"'''^'!  ""*//,  ^^^ 
dentin  'b  b,  Laver  of  odontoblasts,  e,  c.  Transparent  zone  between  the  odontoblasts 
and  the  cells  of  the  pulp  proper,  d,  d.  Layer  of  cells  closely  packed  together,  e  e, 
B^ood  vessels,     f.  f,  Cells  less  closely  placed  toward  the  central  portions  of  the  pulp. 

Fig  -'98  Odontoblasts  clinging  to  a  fragment  of  imperfectly  developed  dentin. 
The  tissue  was  pulled  awav  iu  mounting  the  section.  The  cells  are  drawn  just  as  they 
lav  distorted  in  the  mounting,  but  a  good  idea  is  given  of  their  true  form. 


DENTAL   PULP,    HISTOLOGY,    PHYSICAL   FUNCTIONS.  235 


THE  DENTAL  PULP 
HISTOLOGY  AND  PHYSICAL  FUNCTIONS 

ILLUSTRATIONS:    FIGURES  297-303. 

THE  dental  pulp  is  that  bit  of  soft  tissue  which  fills  the  pulp 
chamber  and  root  canal,  or  canals,  within  the  tooth.  The 
structure  of  the  puJp,  the  more  important  cellular  elements  and 
their  functions  will  be  described. 

The  cellulae  elements. 

The  mass  of  the  tissue,  particularly  in  the  bulb  of  the  pulp, 
is  almost  of  a  gelatinous  character,  very  much  like  the  gelatinous 
tissue  of  the  fetus.  It  is  therefore  but  a  partially  developed 
tissue.  This  tissue  is,  however,  in  certain  parts  fairly  well  filled 
with  cellular  elements.     (See  Figure  297,  also  Figure  35.) 

In  the  root  portion  these  cells  are  fusiform  and  tolerably 
abundant.  Each  cell  gives  off  a  process  from  each  end,  which 
rapidly  becomes  smaller  until  it  is  a  mere  thread,  which  can  be 
seen  only  with  the  highest  power  of  the  microscope.  These 
threads  wind  about  among  the  cells  and  through  the  gelatinous 
portion  of  the  tissue,  often  filling  it  very  thickly  with  the  minute 
thread-like  extensions.  In  the  bulb  of  the  pulp,  pai'ticularly  of 
the  molars,  and  in  the  larger  pulps  of  the  incisors  and  cuspids, 
the  cells  are  more  sparsely  placed,  and  are  larger.  They  may 
be  round  or  cubical  in  form,  each  cell  giving  off  a  numlier  of 
these  processes  which  radiate  in  every  direction  through  the 
gelatinous  mass,  curving  here  and  there.  The  fusiform  cells  in 
the  root  portion  are  disposed  with  their  length  parallel  with  the 
length  of  the  root  canals,  but  in  the  bulbal  loortions  of  the  pulps 
such  relation  is  lost.  In  the  root  portion  the  cells  are  sufficiently 
numerous  to  form  a  fairly  close  tissue.  In  the  ])ulbal  portion 
they  are  not  so  plentiful. 

In  a  tolerably  thick  section  brought  under  the  microscope 
the  cellular  elements  will  seem  plentiful,  even  in  the  bulb  of  the 
pulp,  but  if  the  section  be  a  very  thin  one,  the  cells  are  seen  to  be 
separated  from  each  other  to  such  an  extent  that  they  fail  to 


236  SPECIAL   DENTAL   PATHOLOGY. 

touch  and  unite  with  each  other  to  form  a  complete  cellular 
tissue,  much  of  the  gelatinous  mass  appearing  as  a  clear  space 
except  for  the  windings  of  the  very  fine  processes  given  off  from 
the  cells. 

In  the  ordinary  illustrations  of  pulp  tissue,  particularly  in 
the  photographs,  little  is  shown  of  these  very  fine  processes 
because  they  are  too  small  for  the  camera  to  take  note  of  them. 
Near  the  cell,  a  portion  of  the  process,  which  is  larger  than  the 
rest,  is  generally  shown,  but  even  this  is  absent  from  many 
photograplis.  Some  idea  of  these  processes  may  be  obtained 
from  Figure  297. 

The  odontoblasts.     Fibeils  of  Tomes. 

All  around  the  periphery  of  the  pulp  there  is  a  zone  in  which 
the  cellular  elements  are  more  closely  ]^laced,  forming  what 
would  seem  to  be  a  higher  grade  of  connective  tissue,  but  even 
tliis  is  very  imperfect.  Upon  the  surface  of  the  pulp  tissue, 
between  it  and  the  wall  of  the  dentin  enclosing  it,  there  is  a  layer 
of  small  elongated  cells,  which,  when  cut  through  perpendicu- 
larly with  their  length,  look  like  a  layer  of  fine  columnar  epithe- 
lium. These  cells  are  called  odontoblasts  and  their  principal 
functions  are  the  building  of  the  dentin,  the  maintenance  of  its 
vitality,  and  the  transmission  of  the  sense  of  pain.  They  also 
have  what  seems  to  be  the  function  of  protecting  the  pulp  from 
exposure  ))y  building  secondary  dentin  in  response  to  certain 
stimuli.  This  will  be  discussed  in  the  consideration  of  calcifica- 
tions within  the  pulp  chamber. 

The  odontoblasts  are  very  closely  placed.  (See  Figures 
297,  298  and  299.)  Each  of  these  cells  gives  off  a  process  which 
enters  one  of  the  dentinal  tubules  and  passes  from  the  pulp 
through  the  dentin,  usually  in  a  somewhat  curved  direction,  and 
ends  at  the  dento-enamel  junction  in  the  crown  portion,  or  at 
the  dento-cemental  junction  in  the  root  portion.  These  are  the 
fibrils  of  Tonnes,  or  the  dentinal  fibrils  discovered  by  John 
Tomes,  about  1840.  These  fibrils,  which  radiate  through  the 
dentin  in  every  direction,  give  sensitiveness  to  this  tissue. 
Indeed,  each  of  these  fibrils  seems  to  be  an  extended  portion  of 
the  odontoblast.  (See  Figures  297,  302  and  303.)  The  odonto- 
blast itself  is  apparently  a  very  sensitive  element  of  the  pulp 
tissue,  and  by  means  of  the  fibrils,  conveys  that  sensitiveness 
from  all  parts  of  the  dentin. 

Blood  vessels. 

The  pulp  tissue  has  a  fairly  abundant  circulation  of  blood, 


DENTAL    PULP,    HISTOLOGY,    PHYSICAL   FUNCTIONS.  237 

conveyed  to  it  by  one  or  more  arteries,  accompanied  by  return- 
ing veins,  which  pass  into  it  through  the  apical  foramen  in  the 
fully  developed  tooth.  (See  Figure  300.)  In  the  formative 
stage  of  the  tooth  the  blood  supply  is  much  more  abundant,  the 
tissue  of  the  future  pulp  having  a  broad  base  through  which 
many  arteries  enter.  As  the  growth  continues  and  the  pulp  is 
narrowed  down  to  adult  dimensions  of  the  pulp  chamber,  this 
blood  supply  is  cut  off  more  and  more,  until  often  there  is  but 
a  single  minute  artery  entering  the  tissue,  accompanied  by  a 
returning  vein.  This  artery  begins  to  break  up  in  the  canal 
portion  of  the  pulp,  sending  branches  to  all  parts,  and  this  is 
continued  even  in  the  bulbal  portion,  until  it  is  divided  into  fine 
arterioles,  which  approach  the  layer  of  odontoblasts  previously 
mentioned.  These  again  divide  into  a  plexus  of  capillaries, 
which  are  especially  abundant  near  the  pulpal  ends  of  the  odon- 
toblastic layer.  The  blood  supply  continues  to  be  fairly  rich  in 
the  pulp  of  the  adult  tooth. 

Walls  of  the  blood  vessels.  The  walls  of  the  blood  vessels 
of  the  pulp  are  unusually  thin ;  this  is  another  expression  of  the 
imperfect  development  of  the  organ  from  the  connective  tissue 
standpoint.  (See  Figure  301.)  It  seems  that  the  pulp,  being 
housed  in  the  pulp  chamber,  where  there  is  no  opportunity  what- 
ever under  normal  conditions  for  any  touch  of  extraneous  mat- 
ter with  its  tissue,  is  poorly  provided  in  the  thickness  of  the 
walls  of  its  blood  vessels.  This  may  also  be  due  in  part  to  the 
fact  that  the  tissue  is  housed  and  completely  fills  the  space  of 
the  pulp  chamber,  and  the  blood  vessels  derive  some  support  in 
that  way. 

At  any  rate,  the  walls  of  the  blood  vessels  are  very  thin  and 
the  muscular  coating  of  the  arteries  is  very  slight.  This  being 
the  case,  any  unusual  blood  pressure  is  liable  to  expand  some  of 
the  arteries,  while  others  collapse  to  make  room,  and  also  the 
veins  may  collapse  in  any  such  unusual  blood  pressure.  This 
causes  the  pulp  to  be  especially  influenced  by  thermal  changes. 
Each  thermal  change,  whether  it  is  to  greater  heat  or  to  greater 
cold,  produces  a  shock  which  calls  to  the  pulp  a  greater  amount 
of  blood,  causing  a  twinge  of  pain  which  soon  passes  away. 
This  is  normal  to  the  pulp.  This  condition  of  the  pulp  and  its 
arteries  renders  it  particularly  liable  to  hyperemia  developed  by 
excessive  thermal  changes,  in  which  the  pulp  tissue  becomes 
much  overcrowded  with  blood.  It  is  a  condition  that  must  be 
reckoned  with  in  practice  and  will  be  treated  more  fully  a  little 
later. 

23 


238  special  dental.  pathology. 

Nerves  and  nerve  functions. 

The  nerv^e  supply  is  derived  from  the  nerve  filament,  or 
filaments,  which  enter  the  apical  foramen.  These  are  also  dis- 
tributed principally  along  the  layer  of  odontoblasts,  and  naked 
nerve  filaments  are  frequently  found  among  or  between  the 
odontoblasts,  their  endings  seeming  to  be  upon  the  pulpal  ends, 
or  among  the  cells  of  the  odontoblastic  layer.  These  nerve  fila- 
ments do  not,  however,  enter  the  dentinal  tubules,  so  far  as  has 
yet  been  satisfactorily  demonstrated.  They  give  the  pulp  its 
sensitiveness,  and  the  odontoblastic  layer  with  its  filaments  con- 
veys the  sensitiveness  from  all  parts  of  the  dentin. 

This  is  the  one  place  in  the  minute  anatomical  structure  of 
tissue  in  which  sensitiveness  without  nerves  seems  to  be  demon- 
strable, and  gives  prominence  to  the  idea  that  it  is  the  cellular 
elements  which  are  sensitive,  and  that  it  is  the  function  of  the 
nerve  to  convey  sensitiveness.  True,  nerves  may  have  sensitive- 
ness of  their  own,  but  the  conveyance  of  sensitiveness  or  other 
impulses  is  the  important  function  of  nerve  tissue.  The  sensi- 
tiveness of  the  cellular  elements  is  carried  by  them  to  the  brain, 
and  the  expression  of  pain  is  produced  upon  the  sensorium. 
That  the  cellular  elements  are  themselves  sensitive  may  be 
demonstrated  by  microscopic  study  of  them  under  special  condi- 
tions in  which  they  can  be  seen  while  active. 

The  ameba  displays  this  sensitiveness  when  it  is  in  motion 
upon  the  stage  of  the  microscope  in  a  fluid  particularly  designed 
for  this  purpose.  It  will  be  seen  to  give  out  its  pseudopodia  and 
move  about  in  the  way  of  an  ameba,  picking  up  things  which  it 
may  find  in  the  water  and  taking  them  into  its  mass.  While  it 
is  thus  active  a  little  jar  upon  the  stage  will  cause  the  cell  to 
suspend  its  work  and  roll  uj^  into  a  round  ball.  When  allowed 
to  remain  quiet  for  a  time,  it  will  resume,  and  another  jar  will 
cause  the  same  sensitiveness  to  appear. 

As  the  ameba  has  sensitiveness  within  its  own  mass,  so  the 
cells  in  the  higher  animals,  each  has  its  own  individual  sensitive- 
ness and  responds  to  injury.  It  is  the  function  of  the  nerve  to 
convey  this  expression  of  sensitiveness  to  the  sensorium,  where 
it  is  registered  as  conscious  pain,  or  conscious  sensation.  There 
is  therefore  a  division  between  the  function  of  the  ordinary  cell 
and  the  function  of  the  nerve,  though  this  does  not  prevent  the 
nerve  itself  from  having  its  own  sensation  ;  but  it  is  a  mistake  to 
suppose  that  every  sensation  is  a  nerve  pain.  This  will  be 
understood  better  perhaps  by  the  illustration,  Figure  303.     This 


DENTAL   PULP,    HISTOLOGY,    PHYSICAL   FUNCTIONS.  239 

is  an  example  of  sensitive  tissue  in  which  no  nerve  is  touched, 
as  in  sensitive  dentin. 

Sensory  function  of  the  pulp.  In  sensory  function  the 
pulp  would  seem  to  be  similar  to  other  connective  tissues  of  the 
body.  It  exhibits  pain  upon  touch,  cutting  or  other  injury  of 
its  substance.  This  pain  is  sharp  and  lancinating.  The  sensi- 
tiveness is  more  distressing  than  that  of  cutting  the  ordinary 
tissues;  so  much  so  that  it  is  universally  dreaded  by  patients. 
Every  part  of  this  tissue  seems  to  possess  this  exquisite  sensi- 
tiveness. I  have  had  a  number  of  instances  in  practice  in  which 
I  could  examine  this  critically  in  different  parts  of  a  widely 
exposed  pulp.  In  different  states  of  irritability  wide  differ- 
ences are  found  in  the  sensitiveness  of  the  pulp.  I  have  exam- 
ined a  number  of  pulps  when  laid  bare  by  accidents  which  have 
broken  the  teeth,  exposing  a  considerable  amount  of  pulp  tissue. 
In  some  of  these  cases,  seen  early  after  the  accident,  the  pulp 
was  insensitive  and  blanched,  showing  its  susceptibility  to  shock. 
The  shock  of  breaking  the  tooth  seemed  to  have  obliterated  sen- 
sation for  the  time,  but  by  waiting  for  a  time  the  sensitiveness 
returned  and  it  became  reddened,  hypersensitive  and  painful. 
Then  the  slightest  touch  would  give  exquisite  pain. 

I  think  this  history  is  repeated  in  almost  every  case  of 
breaking  a  tooth  and  exposing  much  of  the  pulp  in  a  sudden  way. 
The  pulp  would  not  seem  to  be  very  much  different  from  other 
tissues  of  the  connective  tissue  group,  and  one  would  naturally 
suppose  that  the  pulp  would  heal  the  same  as  other  connective 
tissues.     This  point  will  be  considered  later. 

In  the  ordinary  diseases  of  the  pulp  its  exquisite  sensitive- 
ness comes  out  boldly  in  the  expressions  of  pain  produced. 
Perhaps  there  is  no  bit  of  tissue  in  the  body  which  becomes  so 
sensitive  as  the  pulp  and  exhibits  more  vague  symptoms.  This 
sensitiveness  is  perhaps  due  in  large  degree  to  the  arrangement 
of  its  tissue,  and  the  thin  walls  of  its  arteries  and  veins.  In 
these  the  variations  of  pressure  by  the  blood  seems  to  have  a 
marked  influence,  causing  the  pain  to  have  a  peculiar  throbbing 
character  much  dreaded  by  persons  who  have  experienced  it. 

The  more  sensitive  nerve  endings  are  along  the  line  of  the 
odontoblasts,  and  with  the  peculiarities  of  the  tissue  which  have 
been  expressed  here,  it  will  be  seen  that  these  are  compressed 
against  the  walls  of  the  hard  dentin  at  every  pulse-beat  in  these 
abnormal  conditions.  This  seems  to  be  an  especially  sensitive 
area  of  the  pulp,  and  the  compression  of  this  layer  of  cells  and 
of  the  fibrils  which  enter  the  tubules  of  the  dentin  produces 


240  SPECIAL    DENTAL    PATHOLOGY. 

excessive  pain  when  the  pulp  is  much  overfilled  with  blood.  .  The 
pulsations  of  arterial  pressure  are  pounding,  as  we  may  say, 
upon  these  sensitive  points.  This  is  to  be  reckoned  with  in  the 
management  of  the  diseases  of  the  pulp. 

Pain  and  touch. 

We  have  seen  that  the  pulp  is  completely  enclosed  in  the  cen- 
tral portion  of  the  tooth  —  the  pulp  chamber  and  root  canals  — 
and  entirely  fills  this  space.  It  is  surrounded  by  hard  tissue  in 
such  a  way  that  under  normal  conditions  notliing  extraneous  can 
touch  it,  and  would  seem  to  be  shielded  very  perfectly  from 
outside  influences,  with  the  exception  of  changes  of  temperature. 
Under  these  conditions  the  pulp  becomes  an  internal  organ,  and 
is  subject  to  much  the  same  conditions  as  to  touch  and  pain  as 
other  internal  organs. 

The  rule  is  that  nature  produces  no  functions  which  can  not 
come  into  use.  Consequently  the  sense  of  touch  is  absent  from 
all  of  the  internal  organs,  but  resides  in  the  sldn  and  in  the 
mucous  membranes  which  line  the  entrances  into  the  body,  as 
the  mouth,  pharjTix,  etc.,  and  the  exits  from  the  body.  It  exists 
in  all  parts  that  can  ordinarily  be  touched  by  the  fingers  or  by 
extraneous  substances  entering  the  body,  but  disappears  as  soon 
as  those  have  fairly  entered  the  body. 

The  sense  of  touch  is  a  localizing  sense  and  should  be  sepa- 
rated completely  from  the  sense  of  pain.  By  the  sense  of  touch 
we  localize  a  touch  on  any  part  of  the  surface  of  the  body.  Pain 
in  and  of  itself  is  not  a  localizing  sense.  Internal  organs  mani- 
fest pain  in  a  vague  way  as  to  localization,  and  often  the  pain 
complained  of  is  at  some  distance  from  the  tissue  in  actual  dis- 
tress. Indeed  we  know  nothing  of  our  internal  organs  except 
what  we  obtain  from  education.  A  man  has  no  idea  of  the 
existence  of  his  stomach  or  of  certain  intestines  from  any  nat- 
ural sensations  of  his  own,  no  matter  how  much  he  may  have 
learned  of  these  in  an  educational  way,  but  in  this  way  he  learns 
to  attribute  certain  sensations  to  certain  organs  vaguely,  and  is 
often  wrong. 

I  remember  the  case  of  a  friend  who  often  complained  of 
pain  in  the  region  of  the  gall  bladder,  and  his  physician  had 
made  a  diagnosis  of  gall  stones.  A  second  physician  made  a 
similar  diagnosis.  In  an  attack  of  pain  which  was  very  much 
worse  than  the  previous  attacks,  a  surgeon  was  called.  This 
surgeon  spent  quite  a  little  time  in  examining  the  case,  and  said 
that  an  operation  was  an  absolute  necessity  and  that  it  should 


DENTAL    PULP,    HISTOLOGY,    PHYSICAL   FUNCTIONS.  241 

be  done  at  once.  I  noticed  that  when  the  patient  was  etherized 
and  the  surgeon  took  up  his  knife,  he  cut  for  the  appendix,  and 
he  was  right.  This  is  one  illustration  of  how  one  may  be 
deceived,  and  how  even  well-informed  physicians  may  be  mis- 
taken as  to  the  location  of  internal  injury  or  disease,  by  the 
manifestation  of  pain.  Physicians  and  surgeons  learn  by  their 
study  of  the  peculiarities  of  pain,  and  particularly  through  their 
observation  of  the  interferences  of  function,  to  make  proper 
diagnoses  in  many  cases  in  which  the  pain  is  not  definitely 
located  by  the  patient. 

Pulp  an  internal  organ.  The  pulp  is  an  internal  organ 
and  shows  all  the  vagaries  as  to  its  location  of  pain  that  are 
found  in  other  internal  organs.  If  a  pulp  has  become  exposed 
from  decay  in  some  hidden  away  locality,  which  has  not  been 
discovered  by  the  patient  or  dentist,  the  patient  is  liable  to  locate 
that  pain  anywhere  on  that  side  of  the  face.  It  may  be  in  the 
teeth  or  in  the  jaws,  or  at  some  distance  from  the  teeth  in  the 
face,  head,  ear  and  various  other  localities,  and  may  display  a 
peculiar  disposition  to  appear  first  in  one  place  and  then  in 
another.  This  is  liable  to  lead  to  errors  in  diagnosis  unless  it  is 
understood  and  carefully  guarded. 

It  is  common  for  patients  to  refer  pain  to  another  tooth  than 
the  one  which  is  diseased,  or  even  to  the  opposite  jaw.  If  the 
diseased  tooth  is  in  the  lower  jaw,  the  patient  may  refer  the  pain 
to  a  tooth  in  the  upper  jaw,  on  the  same  side  of  the  mouth.  This 
is  comparatively  common  in  cases  where  the  diseased  tooth  has 
a  cavity  in  a  position  unsuspected  by  the  patient,  as  in  the  proxi- 
mal surfaces  near  to  or  partly  covered  by  the  gingivae.  If  there 
is  another  tooth  in  the  same  side  of  the  mouth  known  to  have  a 
cavity,  the  patient  is  very  liable  to  attribute  the  pain  to  this 
other  tooth,  an  examination  of  which  may  show  that  the  cavity 
is  not  of  sufficient  depth  to  be  liable  to  produce  inflammation  of 
the  pulp. 

Once  during  my  practice  a  good  Irish  lady  applied  to  me. 
She  had  been  suifering  very  severely  for  some  weeks  with  vio- 
lent toothache  which  she  attributed  to  one  of  the  bicuspids  in 
the  upper  jaw.  In  listening  to  her,  I  found  that  she  had  already 
been  to  two  dentists,  both  of  whom  had  refused  to  extract  a  tooth 
for  her ;  or  rather,  she  would  not  permit  them  to  do  so,  because 
of  a  disagreement  as  to  the  tooth  causing  the  pain.  The  dilemma 
thus  plainly  presented  to  me,  and  the  fact  that  the  poor  woman 
was  almost  crazy  with  pain,  induced  me  to  extract  the  first  molar 
in  the  lower  jaw  instead  of  the  upper  ])icuspid,  without  saying  a 


242  speciaIj  dental  pathology. 

word  to  her  about  it.  She  was  very  wroth,  and  gave  me  several 
pretty  sharp  pieces  of  her  mind.  I  finally  told  her  to  come  and 
see  me  three  days  later  when  we  could  talk  the  matter  over. 
I  knew  full  well  that  her  pain  would  cease,  and  she  came  back 
and  acknowledged  that  it  had  ceased,  but  how  it  was  that  extract- 
ing the  tooth  in  the  lower  jaw  stopped  the  pain  in  the  upper  jaw, 
she  could  not  understand  "a  tall,  a  tall." 

Pain  of  other  diseases  may  simulate  pulp  pain.  There 
are  other  diseases  with  which  pulp  pain  may  become  confused 
because  of  the  similarity  of  the  symptoms.  In  cases  of  tic 
douloureux,  a  true  neuralgia  of  the  fifth  pair  of  nerves,  par- 
ticularly of  the  second  and  third  branches  from  which  the  teeth 
are  supplied,  the  pain  may  be  confused  with  that  caused  by 
inflammation  of  the  pulp.  This  word  tic  means  a  twitch,  and 
douloureux  means  pain.  The  twitching  is  pure  pain  —  nothing 
else  that  can  be  discovered.  It  is  paroxysmal  and  the  paroxysms 
are  very  prone  to  be  brought  on  by  any  slight  touch  on  the  face, 
or  touch  of  the  hairs  of  the  mustache,  or  a  l)reatli  of  cold  air. 
Cases  in  which  the  symptomatology  is  confusing  should  be 
referred  to  a  specialist.  A  full  discussion  of  this  condition 
would  be  out  of  place  in  this  book.  One  in  ordinary  practice 
sees  but  few  cases  of  tic  douloureux ;  indeed,  one  may  spend  a 
lifetime  in  the  practice  of  dentistry  without  seeing  a  case,  but  he 
is  liable  to  be  confronted  with  a  case  at  any  time,  in  which  he 
will  have  to  make  a  diagnosis  between  inflammation  of  the  pulp 
and  this  painful  twitch. 

Patients  will  give  descriptions  of  pain  which  they  refer  to 
the  teeth,  but  which  they  also  refer  to  other  parts.  These 
descriptions  are  often  given  in  language  so  vague  that  it  is  very 
difficult  to  follow  them. 

I  once  had  a  patient  who  complained  of  a  twitching  sensa- 
tion in  his  stomach,  or  in  the  region  of  the  stomach,  and  his 
physician  had  been  treating  him  for  this  without  effect.  Finally 
there  were  some  symptoms  about  the  head  and  jaws,  and  the 
physician  brought  the  patient  to  me  for  an  examination.  In  a 
very  thorough  examination,  I  found  a  point  where  there  seemed 
to  be  no  support  to  the  soft  tissue  over  a  portion  of  the  root  of 
a  tooth,  and  on  pushing  a  sharp  instrument  through  this  it 
dropped  into  a  cavity  in  the  root,  and  a  scream  from  the  patient 
indicated  that  I  had  touched  something  unusually  sensitive. 
I  immediately  extracted  the  tooth  and  found  a  large  absorption 
cavity  exposing  the  tissue  of  the  pulp.  Indeed  the  tissue  of  the 
pulp  itself  was  being  absorbed.     This  ended  the  man's  trouble. 


Fig.  299. 


Fig.  299.  Odontoblasts  sukI  foriiiinij  ilciitiii:  K,  l'\iiniino  I'li.-imi'l.  i).  Forming 
dentin,  o,  Odontoblasts,  op,  Jiody  of  dental  papilla.  (  I'nnn  plintoinicrojrrapli  by 
Kose.) 


*a3 


Fig.  300. 


Fig.  300.    Diagram  of  the  blood  vessels  of  the  pulp.     C.  H.  Stoivell. 


Fig.  301. 


Fig.  301.  A  piilp  1)1()()(1  vessel,  sliovviiijj  the  tliiii  wall:  c,  lilood  corpuscles  in 
the  vessel,  ul,  Blood  vcspel  wall  showing  miclei  of  ciKlolliolial  cells.  N,  Nuclei  of 
connective  tissue  cells  in  the  body  of  the  pulj).  i,  InU'rcellular  substance,  showing  a 
few  fibers.     Noyes. 


Fig.  302. 


Fig.  303. 


Fig.  302.     Diagram  of  odontoblasts  and  dentinal  fibrils.     C.  H.  Stowell. 

Fig.  303.  A  diagram  illustrating  sensation  without  nerves  in  the  dentin.  E, 
Enamel.  D,  Dentin,  o.  Laver  of  odontoblast s.  v,  Pulp  of  tooth  with  nerve  endings 
in  phvsiological  eonneetion"with  thp  odontoblasts.  The  fibrils  of  tiio  dentin  are  pro- 
longiitions  of  the  odontoblasts.  Any  injury  to  them  is  an  injury  to  a  portion  of  the 
odontoblasts  and  is  transmitted  by  the  nerves  to  the  brain. 


DENTAL    PULP,    HISTOLOGY,    PHYSICAL    FUNCTIONS.  243 

These  illustrations  are  given  simply  to  point  out  the  vague- 
ness which  occurs  in  internal  organs  as  to  expression  and  locali- 
zation of  pain,  and  the  tooth  pulp  must  be  considered  an  internal 
organ. 

Sense  of  touch  is  in  pebidental  membrane.  Touch  is  a 
localizing  sense.  Its  function  is  to  point  out  closely  the  part 
of  the  body  touched  and  this  is  done  more  definitely  in  some 
regions  than  in  others.  If  the  surface  of  a  tooth  is  touched  the 
sensation  is  felt.  If  the  pulp  is  removed  and  the  tooth  is  again 
touched,  there  is  no  difference  in  the  sensation.  The  effect  of 
touch  upon  the  tooth  is  not  destroyed  or  changed  by  removing 
the  pulp  because  the  sense  of  touch  for  the  tooth  is  within  the 
peridental  membrane.  If  the  peridental  membrane  is  diseased, 
a  touch  upon  the  tooth  may  be  felt  both  as  touch  and  pain,  because 
of  the  inflammation.  The  response  is  registered  on  the  sensoriuin 
as  both  touch  and  pain.  All  of  this  should  be  kept  in  mind  in 
making  examinations.  Many  of  these  things  will  be  considered 
in  discussing  the  diseases  of  the  pulp. 

Healing  powebs. 

The  description  I  have  given  thus  far  of  the  tissues  of  the 
pulp  and  of  its  functions  would  indicate  that  the  power  of  heal- 
ing is  very  low  in  this  organ,  and  this  agrees  with  clinical 
observation.  Indeed,  the  rule  is  that  in  the  adult  tooth  any 
touch  of  the  pulp  tissue  in  excavating  cavities  which  is  sufficient 
to  draw  blood,  will  eventually  destroy  the  whole  of  the  pulp. 
Such  an  injury  fails  to  heal  by  any  treatment  yet  devised.  Some 
exceptions  to  this  rule  may  have  occurred  under  peculiarly 
favorable  conditions,  but  the  rule  holds  good  in  such  a  large 
majority  of  cases  that  we  must  regard  these  as  exceptions.  This 
is  partly  due  to  the  fact  that  the  mutilation  in  these  instances 
is  of  the  very  sensitive  odontoblastic  layer,  the  regeneration  of 
which  when  injured,  is  in  great  doubt.  It  is  possible  that  in  the 
child's  tooth,  before  the  full  development  of  the  roots,  some  of 
these  injuries  may  be  bridged  over  and  in  a  very  short  time 
become  perfect  again,  not  by  the  multiplication  of  the  odonto- 
blasts, but  by  the  falling  together  of  the  odontoblastic  layer  of 
the  neighborhood  and  straightening  into  normal  form.  During 
this  formative  period  the  pulp  chamber  is  becoming  narrower 
and  narrower,  and  the  odontoblastic  layer  is  becoming  more 
crowded  in  the  whole  extent  of  its  surface,  making  a  more  favor- 
able opportunity  for  this  bridging-over  process  in  the  growth  of 
the  dentin.     In  the  adult  tooth  there  is  practically  nothing  of 


244  ^  SPECIAL   DENTAL   PATHOLOGY. 

this  kind  to  favor  the  healing  process,  and  it  is  rare  that  wounds 
heal.  They  generally  produce  an  inflammatory  movement 
which  in  the  end  destroys  the  pulp. 

History  of  efforts  to  save  exposed  pulps  by  capping. 
I  have  seen  cases  in  which  widely  exposed  pulps  have  been 
capped  and  the  results  should  be  regarded  as  successful, 
although  they  could  not  be  taken  as  a  guide  for  treatment. 
I  remember  once  finding,  in  the  mouth  of  a  very  intelligent  per- 
son, an  amalgam  filling  in  a  lower  molar  that  was  then  in  such 
a  state  of  apical  pericementitis  that  in  my  judgment  an  alveolar 
abscess  could  not  be  prevented.  The  patient  told  me  that  the 
pulp  of  this  tooth  had  become  widely  exposed  fifteen  years 
before,  and  that  Dr.  C.  W.  Spalding,  then  in  practice  in  St.  Louis, 
had  capped  it  with  a  piece  of  gold  plate  and  made  a  filling 
against  this  capping,  and  the  tooth  had  done  service,  and  had 
been  comfortable,  during  the  intervening  time.  I  made  a  cut 
across  the  filling  and  broke  it  out  of  the  cavity.  I  was  sur- 
prised to  find  that  the  inflamed  pulp  had  evidently  protruded 
into  the  portion  of  the  cavity  left  vacant  under  the  piece  of  gold 
plate,  filling  it  completely,  and  all  of  this  portion  of  the  pulp 
had  become  calcified.  The  calcification  of  the  pulp  had  contin- 
ued until  the  pulp  tissue  was  strangled  (I  think  that  is  the  best 
term  to  use)  by  the  amount  of  secondary  dentin  which  had  been 
formed.  The  pulp  dies  in  this  way  in  cases  of  extensive  abra- 
sion, as  a  result  of  which  the  pulp  chamljer  becomes  filled  with 
calcific  material.  The  same  result  follows  extensive  erosion,  or 
sometimes  occurs  without  either  abrasion  or  erosion,  and  finally 
leads  to  the  death  of  the  pulp. 

This  was  a  case  of  what  might  be  termed  the  most  radical 
operation  of  capping  a  widely  exposed  pulp,  which  nominally 
would  be  considered  a  successful  case.  However,  the  percen- 
tage of  such  successes  would  be  so  small  that  no  practitioner 
would  be  justified  in  pursuing  such  a  course.  The  accumulation 
of  records  of  such  procedures  seems  to  be  sufficient  to  condemn 
such  efforts. 

Although  but  few  dentists  Y\^ould  to-day  recommend  the 
capping  of  pulps  in  adult  teeth,  there  have  been  several  attempts 
to  revive  the  practice,  generally  by  those  unfamiliar  with  the 
history  of  these  cases,  and  for  this  reason  I  will  add  a  report  of 
my  own  observations  made  many  years  ago. 

Dr.  Witzel,  of  Germany,  wrote  a  considerable  volume  upon 


DENTAL    PULP,    HISTOLOGY,    PHYSICAL   FUNCTIONS.  245 

this  subject,*  in  whidi  he  advocated  various  means  of  treat- 
ment for  exposed,  inflamed  and  suppurating  pulps,  and  even  the 
extreme  procedure  of  the  removal  of  the  bulb  of  the  pulp  found 
in  a  state  of  suppuration,  retaining  the  root  portions  of  the  pulp 
and  capping  them  over.  Other  writings  as  extraordinary  as 
this  may  be  found  scattered  through  our  literature.  Happily 
they  have  had  very  small  influence  in  inducing  men  to  accept 
and  practice  such  procedures,  and  I  think  it  is  now  generally 
understood  by  the  dental  profession  that  such  treatments  are 
pernicious. 

My  observation  of  this  has  been  long  and  continuous.  Quite 
early  in  my  practice  it  became  my  habit  to  have  my  assistant 
place  on  my  desk  the  record  of  each  patient  for  whom  I  had  pre- 
viously operated,  so  that  I  could  see  at  a  glance  what  I  had  done. 
This  led  me  to  question  understandingly  all  cases  in  which  I  had 
capped  pulps,  and  to  make  a  note  of  the  date  of  examination. 
During  the  years  previous  to  1870  I  had  made  a  good  many  of 
these  pulp  cappings  and  had  records  of  the  results.  These 
records  showed  the  loss  of  the  pulp  from  death  in  all  cases  in 
which  I  had  made  cappings  for  adults. 

These  cappings  were  made  by  the  process  most  commonly 
used  by  dentists  at  that  time,  excepting  that  perhaps  I  was  some- 
what more  careful  to  remove  all  decayed  dentin  than  many 
others.  The  pulp  tissue  was  exposed  by  removing  the  softened 
dentin  from  over  it,  or  from  around  it,  if  it  was  fully  exposed 
to  the  access  of  the  saliva,  which  most  of  them  were  not,  for  I  did 
not  often  use  a  capping  in  such  cases.  This  was  done  with  a 
very  sharp,  broad-bladed  spoon  excavator,  which  would  not 
force  the  debris  into  the  pulp  tissue.  Then  the  cavity  was 
flooded  with  phenol,  and  when  wiped  out  I  was  careful  to  note 
whether  or  not  the  pulp  tissue  was  whitened.  If  it  was  not, 
another  application  was  made  after  carefully  drying  the  cavity, 
for  sometimes  it  was  found  that  there  was  an  exudate  from  the 
pulp  which  would  prevent  contact  with  phenol.  Then  a  capping 
of  chloride  of  zinc  was  placed.  This  material  was  then  sold 
under  the  name  Os  Artificial.  "We  did  not  at  that  time  have 
the  phosphate  cements.  The  chloride  of  zinc  would  cause  con- 
siderable pain  unless  the  pulp  had  been  protected  by  the  eschar 
produced  by  the  phenol.  This  material  was  always  made  soft 
enough  so  that  it  could  be  flowed  into  the  cavity  and  produce 

*  Compendium   der  Patholopie  ynd  Therapie  der  Pulpakrankheitcn   dcs  Zahncs, 
von  Dt.  Med.  Adolph  Witzel,  1886. 


246  SPECIAL   DENTAL    PATHOLOGY. 

little  or  no  pressure,  differing  in  that  respect  from  the  phosphate 
cements  being  used  to-day. 

I  give  the  results  in  my  cases  at  that  time,  published  in  the 
Transactions  of  the  Illinois  State  Dental  Society  for  1870, 
page  6,  as  follows : 

**0f  all  the  cases  treated  in  1860,  only  forty-two  have 
remained  under  my  care,  so  that  I  can  trace  them  with  certainty. 
With  these  the  result  has  been  as  follows:  Seven  abscessed 
within  one  year,  nine  were  found  with  pulps  dead  or  abscessed 
in  the  second  year,  eleven  in  the  third  year,  seven  in  the  fourth 
year,  two  in  the  fifth  year,  one  in  the  sixth  year,  one  in  the  eighth 
year,  and  four  of  the  pulps  remain  alive  to-day. 

"In  counting  these,  I  have  only  taken  those  which  were  at 
the  time  considered  successful  cases.  Those  that  failed  within 
one  month  are  not  included.  The  immediate  failures  at  that 
time  will  outnumber  those  of  to-day,  on  account  of  the  greater 
imperfections  in  operating. 

*'It  is  very  important  to  notice  the  ages  of  these  patients, 
and  the  varying  rate  and  time  of  failure.  In  eighteen  cases  they 
were  under  twenty  years  of  age,  while  in  twenty-four  cases,  they 
were  over  twenty  years  of  age.  Of  those  under  twenty,  six 
failed*  in  the  first  year,  four  in  the  second  year,  two  in  the  third 
year,  one  in  the  fourth  year,  and  four  are  successful  after  ten 
years.  Of  those  over  twenty,  one  failed  in  the  first  year,  five  in 
the  second,  nine  in  the  third,  six  in  the  fourth,  two  in  the  fifth, 
one  in  the  sixth,  and  one  in  the  eighth  year. 

''It  will  be  seen  that  all  the  cases  in  patients  over  twenty 
years  of  age  have  failed,  and  that  in  the  successful  cases,  the 
patients  were  under  that  age. 

"In  the  successful  cases  the  fillings  which  were  placed  at 
the  time  of  the  capping,  were  removed,  two  in  the  second  year, 
and  one  in  the  third  year,  and  the  teeth  refilled,  when  the  pulps 
were  found  covered  with  solid  dentin  which  had  been  thrown  out 
over  them.  In  the  eighth  year,  the  fourth  successful  case  was 
found  in  like  condition. 

' '  The  cases  reported  as  failures  did  not  all  suppurate ;  but 
in  some  of  them  the  old  fillings  had  to  be  replaced  by  the  new, 
and  the  pulps  were  found  dead.  My  record,  unfortunately,  only 
shows  which  teeth  had  the  roots  filled,  or  were  extracted,  with- 
out any  reference  to  their  suppuration,  so  that  I  can  not  state 

*  The  word  "  failed  "  in  this  report  represents  the  time  at   which  these  failures 
were  discovered. 


DENTAL    PULP,    HISTOLOGY,    PHYSICAL   FUNCTIONS.  247 

the  exact  number  that  did  actually  suppurate. ' '     My  memory  is 
that  most  of  these  cases  were  found  with  alveolar  abscess. 

Many  dentists  of  my  acquaintance  were  using  this  particu- 
lar mode  of  capping  pulps.  A  very  large  proportion  of  the 
pulps  thus  capped  gave  no  symptom  of  inflammation.  Very 
few  practitioners  of  that  time  kept  records  of  such  cases,  and 
when  patients  returned  to  them  they  were  often  unable  to  tell 
which  teeth  had  had  pulp  cappings,  and  which  had  not;  they 
were  even  unable  often  to  determine  whether  they  had  made 
certain  of  the  fillings.  They  were  therefore  unable  to  know  the 
results  of  their  operations. 

At  that  time  the  discussions  of  the  Society  were  not  taken 
in  shorthand,  and  do  not  appear  in  the  printed  transactions,  but 
I  do  know  that  in  closing  the  discussion  which  followed  this 
paper,  I  urged  the  members  of  the  Society  to  make  records  of 
such  cappings,  also  of  the  conditions  observed  when  patients 
returned  for  examinations,  in  order  to  learn  definitely  what  suc- 
cesses were  attained. 

This  process  of  capping  was  very  generally  abandoned 
within  a  few  years  because  so  many  pulps  died,  and  the  general 
practice  swung  to  the  opposite  extreme,  of  removing  every 
exposed  pulp. 

In  the  report  given  above,  all  of  the  pulps  which  lived  were 
for  persons  under  twenty  years  of  age,  and  all  but  one  were  for 
persons  under  fourteen  years.  Therefore,  the  successful  cap- 
pings were  those  of  the  pulps  in  children's  teeth,  the  root  canals 
of  which  were  still  large.  In  more  recent  years,  I  have  confined 
the  operation  of  capping  to  those  cases  in  which  the  exposures 
have  occurred  very  early  in  life,  because  they  offered  the  great- 
est probability  of  success.  The  technic  of  capping  pulps  will  be 
given  under  the  discussion  of  pulp  treatment. 


248  SPECIAL    DENTAL   PATHOLOGY. 


DISEASES  OF  THE  DENTAL  PULP 

ILLUSTRATIONS:    FIGURES  304-341. 

THE  most  common  diseases  to  which  the  dental  pulp  is  liable 
are  hyperemia  and  inflammation.  To  these  may  be  added 
hypertrophy,  which  occurs  in  some  cases  of  chronic  inflamma- 
tion ;  traumatisms,  including  blows  upon  the  teeth,  broken  teeth, 
and  injuries  to  the  pulp  in  the  excavation  of  cavities  caused  by 
decay;  and  the  calcifications  which  occur,  either  growing  upon 
the  walls  of  the  pulp  chamber,  or  within  the  pulp  tissue  unat- 
tached to  the  walls.  These  calcifications  may  cut  otf  the  pulpal 
ends  of  the  dentinal  fibrils  and  destroy  the  life  of  large  areas  of 
dentin,  perhaps  in  some  instances  including  the  entire  crown 
portion  of  the  tooth.  These  occur  most  as  a  result  of  abrasions 
or  erosions  of  the  teeth,  but  may  occur  without  them.  This 
practically  covers  diseases  of  the  pulp  observed  by  dentists  in 
practice. 

Historical  Statement. 
Previous  to  the  publication  of  the  American  System  of 
Dentistry  in  1886,  there  seems  to  have  been  much  speculative 
consideration  of  inflammation  of  the  pulp,  but  a  review  of  the 
literature  reveals  the  fact  that  practically  no  studies  of  hypere- 
mia of  the  pulp  had  been  made  before  that  time.  Therefore, 
most  of  the  cases  of  hyperemia  must  have  been  classed  as  inflam- 
mations. It  does  not  appear  that  the  diagnoses  were  verified  by 
careful  microscopic  examinations  of  the  prepared  tissue,  com- 
bined with  previous  studies  of  the  symptomatology.  If  they 
had  been  so  studied,  we  can  not  conceive  that  so  many  errors 
could  have  occurred.  Indeed  it  would  seem  that  most  men  have 
considered  that  when  the  pulp  was  painful,  it  was  necessarily 
inflamed. 

This  is  far  from  correct,  for  many  pulps  which  are  painful, 
are  painful  from  hyperemia.  Many  pulps  which  are  inflamed 
are  painful  from  the  hyperemia  accompan3^ng  the  inflammation, 
and  the  symptomatology  is  very  similar  to  that  of  hyperemic 
pulps.  If  one  should  extract  a  painful  tooth  and  afterward 
break  it  open  and  examine  the  pulp  with  the  naked  eye,  or  hand 


DISEASES    OF    THE    DENTAL    PULP.  249 

lens,  and  find  it  very  red  or  turgid  with  blood,  and  on  such  an 
examination  pronounce  it  inflamed,  most  of  the  pulps  from 
aching  teeth  would  be  classed  as  inflamed.  Hyperemic  pulps 
will  show  the  same  turgescence.  For  this  reason,  the  mistakes 
in  classifying  hyperemic  pulps  as  inflamed  pulps  seem  to  have 
been  common  in  the  past. 

A  number  of  writers  have  given  extended  classifications  of 
inflammations  of  the  pulp,  apparently  based  on  microscopical 
examinations  of  the  tissue.  These  can  not  be  distinguished 
clinically,  and,  therefore,  are  not  useful  to  the  general  practi- 
tioner, so  far  as  his  every-day  operations  are  concerned.  They 
are  interesting  as  scientific  studies,  and  in  the  course  of  time  a 
more  critical  observation  of  the  symptomatology,  as  compared 
with  the  particular  form  of  the  inflammatory  process,  as  studied 
in  prepared  sections,  may  become  of  more  importance  than  at 
present. 

From  the  standpoint  of  practical  treatment,  it  is  important 
that  a  different  diagnosis  be  made,  whenever  this  is  possible, 
between  simple  hyperemia  and  inflammation,  because  the  effort 
should  be  made  to  save  all  hyperemic  pulps,  while  practically  all 
inflamed  pulps  must  be  destroyed  and  removed.  Hypertrophy^ 
of  the  pulp  due  to  chronic  inflammation,  in  which  the  pulp  tissue 
is  protruded  through  the  orifice  into  the  cavity  produced  by 
caries  until  it  fills,  or  partially  fills,  the  cavity  of  decay,  is 
always  easily  diagnosed.  Those  cases  due  to  traumatism  are 
usually  recognized  without  diflBculty,  and  the  character  of  the 
traumatism  will  indicate  the  treatment. 

In  the  consideration  of  the  hard  formations,  it  is  of  most 
importance  that  certain  conditions  which  are  known  to  cause 
these  calcifications  be  recognized  early  and  treatment  promptly 
applied.  A  better  Imowledge  of  the  various  forms  of  these  hard 
formations  will  also  be  of  assistance  in  facilitating  their  removal. 

To  show  the  extent  to  which  many  have  gone  in  descrilnug 
inflammation  of  the  pulp  and  the  varieties  assumed  by  it,  I  copy 
here  from  '^Zahnheilkunde,"  by  G.  Preiswerk,  published  in  IDO,*), 
the  following  from  an  index  given  in  the  first  pages  of  the  book, 
''Die  Erkrankungen  der  Pulpa": 

PAGE 

1.  Hyperaemia  pulpae 268 

2.  Pulpitis  acuta  superficialis 271 

3.  4.  u  6.     Pulpitis  acuta  partialis,  totalis  und 

traumatica  271 

24 


250  SPECIAL   DENTAL   PATHOLOGY. 

5.     u  8.     Pulpitis  acuta  partialis  purulenta  und 

Pulpitis  chronica  totalis  purulenta 274 

7.     Pulpitis  chronica  parenchymatosa. . 275 

9.     u  10.     Pulpitis  chronica  hypertrophica  gran- 

ulomatosa  und  sarcomatosa 277 

11.  Gangraena  pulpae 278 

12.  Pulpitis  idiopathica  seu  concrementalis 280 

While  most  of  the  conditions  mentioned  can  be  made  out  in 
an  examination  of  pulps  after  obtaining  and  making  sections  of 
the  tissue,  I  have  failed  to  make  them  out  by  diagnostic  signs 
before  removing  the  teeth  and  bringing  the  prepared  pulp  tissue 
under  the  microscope. 

I  have  taken  careful  notes  of  the  symptoms  in  cases  in 
which  there  was  hyperemia  or  inflammation  of  the  pulp  and 
from  these  have  written  my  conclusions  as  to  the  condition  of 
the  pulp.  Then  I  have  extracted  the  teeth,  prepared  the  tissue 
jind  brought  it  under  the  microscope  for  study.  I  have  repeated 
this  process  for  a  great  many  teeth,  both  before  and  since  my 
writing  in  the  American  System  of  Dentistry,  and  my  conclu- 
sion, after  all  of  these  studies,  is  that  inflammations  of  the  pulp 
in  earlier  stages  can  not  be  differentiated  from  hyperemia;  fur- 
thermore that  it  is  impossible  to  determine  from  the  symptom- 
atology, whether  or  not  inflammation  exists  in  the  pulp.  Many 
pulps  which  are  inflamed  and  suppurating  give  no  symptoms 
whatever.  In  my  examinations  I  classed  widely  inflamed  pulps 
as  hyperemic  pulps,  pure  and  simple.  Indeed,  so  many  errors 
of  diagnosis  occurred  that  I  am  satisfied  that  we  are  unable  to 
differentiate  between  special  conditions  of  inflammation,  as  it 
occurs  in  the  pulp,  by  symptomatology''.  The  only  reliable 
method  of  differentiating  between  hyperemia  and  inflammation 
of  the  pulp,  as  will  be  explained  later,  is  by  determining  whether 
or  not  the  pulp  has  been  actually  exposed. 

Therefore,  such  classifications  of  the  inflammatory  condi- 
tions of  the  pulp  as  the  one  quoted  can  be  of  no  benefit  whatever 
to  the  dentist  in  his  every-day  practice.  In  this  book,  I  shall 
adhere  to  very  much  simpler  divisions  of  the  process  of  inflam- 
mation, as  it  occurs  in  the  pulp.  I  shall  make  a  few  changes  in 
classification  from  what  I  wrote  for  the  American  System  of 
Dentistry  in  1886.  One  of  the  most  prominent  of  these  will  be 
the  classification  of  every  pulp  exposed  to  carious  dentin,  as  an 
inflamed  pulp,  whereas  in  that  writing  I  classified  only  those 
exposed  to  the  saliva  as  being  always  inflamed  pulps. 


diseases  of  the  dental  pulp.  251 

Personal.  Studies  of  Hyperemia  and  Inflammation  of  the 

Pulp. 

In  the  American  System  of  Dentistry,  I  wrote  the  chapter 
on  the  Patholog}'^  of  the  Dental  Pulp,*  and  on  reviewing  my 
presentation  of  the  subject,  I  find  that  I  will  have  but  little  new 
or  ditf  erent  to  present  now. 

In  the  studies  at  that  time,  I  made  microscopic  sections  of 
a  great  many  h\^eremic  and  inflamed  pulps,  including  those  in 
which  the  disease  had  become  severe.  In  all  of  the  cases  there 
was  a  determined  effort  to  capture  the  conditions  of  the  blood 
which  was  present  within  the  pulp  with  its  expansion  of  arteries, 
or  without  this  expansion,  and  keep  careful  notes  of  the  symiJ- 
tomatology  in  each  individual  case  at  the  moment  the  tooth  was 
extracted,  also  of  the  occurrence  of  paroxysms  of  pain,  and  their 
severity.  This  record  was  kept  of  each  such  case  from  the  time 
the  patient  first  presented  until  the  tooth  was  extracted. 

In  some  cases,  the  greatest  degree  of  pain  which  I  could 
produce  by  the  application  of  heat  or  of  cold,  was  brought  about, 
and  the  tooth  extracted  at  the  moment  the  pain  seemed  greatest. 
Immediately  after  the  extraction,  the  tooth  was  caught  with  one 
finger  upon  the  occlusal  or  incisal  edge,  and  one  on  the  apex  of 
the  root,  and  held  so  for  a  few  moments  to  prevent  more  blood 
from  issuing  from  the  pulp.  It  was  then  dropped  into  Miller's 
fluid,  or  some  such  fixative.  Observation  showed  that,  when  so 
treated,  no  more  blood  would  be  lost  from  the  pulp.  A  label 
was  attached  to  the  tooth  by  a  string  which  hung  out  of  the  jar, 
so  that  I  could  put  a  number  of  teeth  into  one  large  jar  of  the 
fluid. 

In  other  cases  the  teeth  were  extracted  when  there  was  no 
pain,  in  the  interval  of  quiet  between  paroxysms,  and  were 
treated  in  the  same  way.  I  collected  specimens  of  teeth  that 
were  showing  moderate  hyperemia,  both  in  the  stage  of  excessive 
pain  and  in  the  stage  of  quiet,  the  various  cases  representing 
])ractically  all  the  features  of  the  pain  in  hyperemia,  including 
pulps  that  were  on  the  point  of  being  destroyed  by  the  disease. 
T  also  included  a  number  of  cases  in  which  the  pulp  had  just 
died,  or  had  very  recently  died,  from  this  cause. 

Technic  of  preparing  specimens. 

After  a  sufficient  time  in  the  Miller's  fluid  for  fixation  and 
considerable  stiffening  of  the  tisssue,  the  teeth  were  cracked  in 
a  strong  vise,  placing  them  so  as  to  produce  pressure  on  the 

*  American  System  of  Dentistry,  Vol.  T,  p.  829. 


252  SPECIAL    DENTAL   PATHOLOGY. 

greatest  portion  of  two  sides,  usually  the  lingual  and  labial  of 
the  front  teeth,  which  were  most  generally  used  for  this  purpose. 

After  cracking  the  tooth  in  the  vise,  it  should  be  placed 
under  running  water  and  washed  moderately  free  from  the 
^filler's  fluid  in  which  it  has  been  soaked.  Sometimes,  with  the 
best  of  care,  the  pulp  tissue  will  be  crushed  and  ruined,  but  in  the 
majority  of  cases,  as  I  have  handled  them,  the  tooth  will  be  split 
lengthwise,  exposing  the  larger  portion  of  the  pulp  in  one  or  the 
other  half.  Sometimes  a  part  of  the  pulp  will  be  held  in  one 
half,  and  another  part  in  the  other  half.  A  fine  needle  may  be 
used  to  advantage  to  free  the  pulp  tissue  from  one  of  the  halves, 
without  injuring  it.  Then  with  the  pulp  lying  in  a  single  half 
of  the  broken  tooth,  one  may  tease  it  out  slowly  and  carefully, 
tiying  always  to  pass  the  needle  between  the  pulp  and  the  walls 
of  the  pulp  chamber  so  as  not  to  disturb  the  relations  of  its 
tissue. 

In  this  it  will  be  discovered,  if  one  is  using  a  magnifying 
glass  and  working  very  carefully,  that  the  fibrils  are  being  pulled 
out  of  the  dentin  in  some  positions.  Over  other  portions  of  the 
pulp  odontoblasts  will  be  pulled  off  from  the  pulp  and  remain 
adhering  to  the  walls  of  the  pulp  chamber.  It  is  quite  desirable 
to  remove  as  much  of  the  odontoblastic  layer  with  the  pulp  as 
possible.  "When  this  has  been  done,  the  pulp  is  placed  in  the 
washing  tray  and  allowed  to  remain  in  running  water  until  all 
traces  of  the  discoloration  by  the  Miller's  fluid  have  been  washed 
out.  The  bit  of  tissue  is  then  ready  for  the  usual  preparation 
for  sectioning  and  staining,  wliich  does  not  differ  from  that 
generally  used  in  the  preparation  of  other  tissues.  It  is  passed 
through  the  usual  alcohol  solutions,  beginning  with  45  per  cent, 
then  60  per  cent,  80  per  cent,  95  per  cent  and  finally  remaining 
some  time  in  absolute  alcohol.  Then  it  may  be  blocked  in 
paraffin  or  celloidin. 

I  have  also  cut  much  of  this  very  delicate  material  in  gum 
arabic.  A  solution  of  gum  arable  is  made  and  filtered.  A  sujffi- 
cient  portion  of  this  is  placed  in  a  dish  and  the  pulp  laid  in. 
The  amount  of  gum  arabic  in  the  solution  should  always  be  such 
that  the  pulp  tissue  will  sink.  It  should  never  float.  If  it  floats 
the  gum  arabic  solution  should  be  diluted  with  water  and  given 
time  for  this  to  become  equally  distributed  before  finally  placing 
the  specimen  in  it.  Then  the  gum  arabic  solution  should  be 
placed  where  there  will  be  a  very  slow  evaporation  of  the  water. 
It  will  become  thicker  and  thicker  from  the  evaporation.  It 
should  require  several  days  in  order  that  the  pulp  tissue  may  be 


DISEASES    OF    THE    DENTAL   PULP.  253 

thoroughly  filled  with  gum  arable.  The  gum  arable  is  veiy 
prone  to  decomposition  and  to  growths  of  mold,  which  may  be 
prevented  by  a  few  small  crumbs  of  camphor  distributed  over 
the  surface.  When  the  solution  has  become  sufficiently  stiff 
that  it  may  be  built  up  on  a  cork,  or  other  suitable  block  which 
may  be  held  by  the  jaws  of  the  sectioning  machine,  this  should 
be  done,  and  the  pulp  carefully  lifted  and  placed  upon  this  as  it 
dries  a  little.  Then,  as  this  material  is  clear,  and  the  position  of 
the  pulp  may  be  accurately  seen,  it  should  be  covered  with  more 
of  the  thick  solution,  so  that  the  pulp  will  be  well  buried  in  it, 
and  then  it  should  be  manipulated  so  as  to  bring  the  pulp  in  the 
exact  position  wanted  for  sectioning. 

In  this  condition  it  is  floated  by  attachment  to  a  cork,  if  the 
cork  has  not  been  used  to  begin  with,  on  the  surface  of  alcohol. 
The  alcohol  will  take  the  water  from  the  gum  arable  and  cause 
it  to  become  hard.  A  solution  of  about  70  per  cent  alcohol 
should  first  be  used.  Within  a  few  days  it  may  be  increased  to 
95  per  cent.  Careful  examinations  of  the  mass  should  be  kept 
up  during  this  time,  to  see  to  it  that  it  is  not  rendered  too  hard 
and  brittle.  When  it  is  judged  to  be  hardened  sufficiently,  the 
whole  should  be  removed  from  the  alcohol  and  covered  very 
closely  to  prevent  further  drying  of  the  surface.  It  should 
remain  thus  covered  for  a  day  or  two,  because  the  surface  of  the 
gum  arable  will  at  first  be  dried  very  much  more  than  the  inte- 
rior, and  during  this  time  of  waiting,  the  drying  will  be  equal- 
ized so  that  the  whole  of  the  specimen  is  of  equal  hardness.  It 
requires  some  experience  with  this  material  to  attain  just  the 
exact  conditions  which  will  give  the  best  results. 

When  the  sections  are  cut,  laid  on  a  cover-glass  and  mois- 
tened with  water,  they  quickly  unfold,  and  will  usually  lie  in 
very  perfect  position.  The  gum  arable  dissolves  in  the  water, 
and  this  may  be  drained  later,  leaving  the  section  upon  the  cover- 
glass  without  disturbance.  It  is  well  to  have  the  cover-glass 
covered  with  some  substance  that  will  cause  the  section  to 
cohere,  as  ecjual  parts  of  egg  albmnen  and  glycerin.  Then  the 
staining  can  be  carried  out  the  same  as  in  staining  other  sections 
of  tissues,  and  brought  under  the  niieroscope  in  good  condition 
for  examination. 

This  is  a  brief  detail  of  the  plans  I  have  used  in  studying 
the  conditions  of  the  pulp  in  hyperemia,  inflammation,  in  sup- 
puration, and  in  fact  all  of  the  diseases  known  to  it,  and  these 
studies  are  the  basis  of  most  of  the  descriptions  of  the  tissues 
and  tissue  changes  in  diseases  of  the  pulp,  which  I  shall  giv^e. 


254  SPECIAL   DENTAL   PATHOLOGY. 


HYPEREMIA  OF  THE  DENTAL  PULP 

ILLUSTRATIONS:    FIGURES  304-307. 

Hyperemia  of  the  pulp  consists  essentially  in  the  expansion 
of  the  blood  vessels,  principally  the  arteries,  during  any  sudden 
abnormal  blood  pressure.  This  is  of  frequent  occurrence;  so 
frequent,  indeed,  that  cases  are  almost  constantly  presenting. 
In  general,  hyperemia  is  seen  as  an  accompaniment  of  another 
disease,  and  is  not  regarded  as  a  disease  in  itself.  If,  however, 
a  femoral  artery  is  tied  on  account  of  an  aneurism,  and  the 
circulation  in  the  leg  proves  insufficient  because  of  this,  a  general 
passive  h^q^eremia  of  the  leg  may  occur,  often  with  fatal  results. 
The  venous  h>T)eremia,  which  gradually  approaches  stasis, 
becomes  a  pathological  condition,  rather  than  a  symptom.  The 
hyperemia  of  the  tooth  pulp,  in  distinction  from  this,  is  always 
an  arterial  hyperemia. 

Etiology. 

The  most  frequent  cause  of  hyperemia  of  the  pulp  is  a 
sudden  change  of  temperature.  Any  sudden  change  from  the 
normal  temperature,  either  too  hot  or  too  cold,  seems  to  affect 
prominently  the  blood  pressure  in  the  pulp,  causing  an  inrush  of 
blood  which  gives  a  more  or  less  sharp  twinge  of  pain  for  the 
moment,  and  then  passes  away.  This  is  a  physiological  hypere- 
mia of  the  pulp.  Practically  every  normal  pulp  will  give  this 
expression  when  either  ice-water  or  a  hot  drink,  or  very  hot  or 
very  cold  food  of  any  kind,  is  taken  into  the  mouth.  This  is  not 
abnormal,  but  normal  to  the  pulp.  Pathological  hyperemia  is 
an  extraordinary  excitation,  in  which  the  function  is  forced 
beyond  normal  limits,  and  the  larger  majority  of  cases  arc 
brought  on  by  sudden  exposures  to  heat  or  to  cold,  which  are 
sufficient  to  cause  this  normal  function  to  become  excessive  and 
morbid. 

There  are  some  other  conditions  which  produce  hyperemia 
of  the  pulp.  Irritation  of  the  dentinal  fibrils  in  the  beginnings 
of  caries  seems  sometimes  to  render  the  pulp  more  excitable, 
and  may  serve  to  precipitate  a  case  of  hyperemia.  This  occurs 
most  frequently  as  a  result  of  broad  gingival  third  decays  in 


Fig.  304. 


Fig.  3(H). 


Fig.  304.  Hypereniin  ni'  tln'  ilfiitiil  imlji,  sluiwiiifi  tlic  natural  iiij«H'tion  of  the 
vessels:  a,  a,  Layer  of  niloiituMasts.  1).  li.  1).  1>,  N'.'sscis  ilistciKle.l  with  blood. 
C,  C,  C,  e,  Points  from  wliicli  the  I.Io'mI  has  faHni  in   lian.llin;;'  tlic  section. 

Fig.  305.  Dilatc<l  liUiod  vessels  from  tlio  ilmtal  iMii|i  in  li_v|>ci-cinia.  from  tootli 
extracted  during  a  paroxysm  of   intense  pain. 

Fig.  306.     A  small  vein   from  a  liyperemic   pulp,  yreatly   ilistende.l  and   nodulated. 

*24 


Fig    307. 


Fig  307.  Section  of  hypercMiiic  inil]..  showing  aneiirisinal  dilatations  of  the 
vessel  extravasations  of  blood,  and  red  blood  disks  escaped  apparently  by  diapedesis: 
a.  a,  Dilated  vessels,  b.  b,  b,  Extravasatod  bloo<l.  Besides  this,  red  blood  disks  are 
pientifiiUy  distributed  everywhere  in  the  neighborhood  of  the  veins.  The  tooth  was 
extracted  during  a  paroxysm  of  pain. 


"-/aw  ^ 


1^: 


/« 


Fig.  308. 


Fig.  308.  Inflammation  of  dental  pulp:  a,  a,  Xornial  colls,  h.  h.  h.  !>,  Iiiflam 
matory  elements,     c,  rolls  in  process  of  liivisioii. 

Fig.  309.  Section  of  iloTilal  pulp,  sliowiii'j  <lil;itioii  iuhI  .'on-^fsl  ion  of  hlooil 
vessels  and   escaped   corpustdes. 


^^&i 


-*5^--' 


Fig.  310. 


Fig.  311. 


Fig.  310.  Minute  inflanmiatory  focus  within  the  tissues  of  the  pulp:  a,  a, 
Arterial  twigs,     b,  A  nerve  bundle,     e,  Colleetion  of  leucocytes. 

Fig.  311.  Diagram  of  !(i\\cr  uiiil;ir,  witli  ciiics  a1  ii  which  exposed  the  pulp. 
The  darkened  portion  jit  !>  shuws  the  extent  (it  the  inllannuation.  The  rest  of  the 
organ  was  free  from  intlanuiiatdry  elian^c  Within  tlie  circle  the  inflamed  tissue  of 
the  i)ulp  is  shown,  ;;  part  lia\in<i  liei'U  dest  roved  liy  sii]iimration  at  a.  The  odonto- 
blasts are  undermined  ;it  li.  'I'lie  MciimI  vessels  whicli  were  filled  with  blood  clot  in  the 
section  are  left  blank    liere,  that    they   may   be   mnre   apparent. 


a- 


4^  /a\y,> 


'/.I. 


^^ 


1     M 


a     ''"Si 


-I  "C     % 


J'lG    n2 


portion  of  t  10  pnln  liad  l)ooii  f1<.«t.- ,v-.,i  i,  ■    .     »,    i  iis       a   jtait    ot    the   crown 

it   will   ,...  noto<!  lunvX' ;  ;1  t       tr^  =""'  '"  ^"^  T-"'"^  P-'ti- 

veins  M„.l   converging  to  the  centor  '  "  l'"'--'""«  the  conrso  of  the 


Fig.  313. 


Fig.  313.     Abscess  within  the  tissues  of  the  pulp.     The  field  includes  about  one- 
half  of  the  little  pocket  of  pus. 


Fig.  m.     Chronic  innani.n:.ii..i.   of  tlu-  pulp,  n.volation   an.l  .iogonoration. 


Fig.  315. 


Fig.  315.  Diagram  of  a  hnvcr  first  iiKilar,  with  a  cavity  at  a  completel.y  filled 
by  a  hypertrophy  of  the  \m\\i,  which  has  frrowu  out  through  the  orifice,  exposing  the 
pulp  at  b.  In  "the  circle,  the  liyiuTtropiiied  i)ulp  tissue  is  shown.  It  is  composed 
almost  entirely  of  granulation  tissue  of  a  very  primitive  type:  a,  a,  Covering  of 
epithelium  presenting  papilla",     b,  Epithelium  apparently  without  papillae. 


HYPEREMIA    OF    THE    DENTAL   PULP.  255 

the  buccal  surfaces  of  the  bicuspids  or  molars,  or  in  the  labial 
surfaces  of  the  incisors,  in  which  tlie  ends  of  many  dentinal 
fibrils  are  laid  bare. 

Hyperemia  is  very  commonly  the  result  of  heat  generated 
in  polishing  fillings,  either  by  rapidly  revolving  disks,  or  by  the 
vigorous  drawing  of  tapes  back  and  forth  on  proximal  surfaces. 
A  filling  which  is  placed  over  a  nearly  exposed  pulp  may  cause 
hyperemia  by  the  rapid  conduction  of  thermal  changes.  A  very 
large  filling  may  cause  a  hyperemia  on  account  of  the  broad  con- 
tact of  its  inner  surface  with  many  dentinal  tubules,  even  though 
the  changes  of  temperature  in  the  mouth  are  not  extreme.  The 
grinding  away  of  the  enamel  of  a  vital  tooth  will  often  cause 
hyperemia,  either  on  account  of  the  heat  or  by  the  irritation  of 
the  ends  of  the  dentinal  fibrils  at  the  dento-enamel  junction, 
even  though  the  tooth  is  kept  cool  by  a  jet  of  water  or  otherwise. 
In  the  so-called  oral  prophylaxis  treatments  of  the  more  radical 
nature  advocated  by  some,  in  which  portions  of  the  enamel, 
whether  decayed  or  not,  are  ground  away  to  make  it  smooth,  a 
very  definite  hyperemia  will  result  in  many  cases,  and  this  should 
always  be  a  warning  that  the  vitality  of  the  pulp  is  endangered. 

I  have  sometimes  created  hyperemia  in  testing  teeth  to 
determine  the  vitality  of  the  pulps,  by  applying  gutta-percha 
which  was  too  hot.  This  produced  severe  pain  at  the  moment, 
and  the  teeth  were  hypersensitive  for  some  time  aftei-ward. 

Pathological  changes. 

In  the  majority  of  the  milder  cases  of  hyperemia  in  which 
the  teeth  have  been  extracted  during  the  time  of  freedom  from 
pain,  practically  nothing  abnormal  is  found.  They  would  be 
passed  as  normal  in  any  collection  of  microscopic  specimens  of 
tissues  of  the  pulp ;  but  in  similar  cases,  in  which  the  teeth  were 
extracted  during  paroxysms  of  pain,  considerable  blood  over  the 
normal  amount  is  always  found  in  the  arteries,  and  some  of  the 
arteries  are  more  or  less  expanded  in  parts  of  their  course. 
(See  Figures  304,  305,  306  and  307.) 

Some  cases,  in  which  the  history  showed  the  paroxysms  of 
pain  to  have  been  longer  in  their  duration,  and  in  which  the 
paroxysms  themselves  had  been  very  severe,  have  shown  more 
blood  than  normal,  and  expansion  of  arteries,  even  though  the 
teeth  were  extracted  during  the  time  of  the  most  complete  cessa- 
tion of  pain.  In  those  cases  in  which  the  tooth  was  extracted  at 
the  moment  of  the  severest  pain,  the  normal  arrangement  of  the 
arterial  system  of  the  pulp  was  almost  completely  destroyed. 


256  SPECIAL   DENTAL    PATHOLOGY. 

Some  arteries  were  greatly  expanded  and  filled  with  blood,  while 
others  near  by  were  collapsed.  Distortions  of  this  character 
were  seen  throughout  the  tissue  of  the  pulp.  In  none  of  these 
was  there  any  actual  sign  of  inflammation. 

In  those  cases  in  which  the  pulp  had  just  died,  or  in  which 
its  death  had  occurred  within  a  few  hours  previously,  this  distor- 
tion of  the  tissues  of  the  pulp  was  very  much  greater,  and  in 
addition  to  this  the  tissue  was  generally  very  much  filled  with 
red  blood  corpuscles  which  had  passed  through  the  walls  of  the 
blood  vessels  into  the  tissues,  causing  the  pulp  to  appear  almost 
like  a  blood  clot. 

Symptoms. 

The  symptoms  of  hyperemia  consist  of  vaiying  degrees  of 
pain.  Many  cases  produce  a  moderate  excess  of  pain  in  a  par- 
ticular tooth,  or  in  several  teeth,  which  endures  a  little  longer 
and  is  more  severe  than  would  be  called  the  normal  condition  of 
pain  in  taking  food  or  drinks  that  are  hot  or  cold.  Some 
patients  are  much  disturbed  when  a  tooth  is  sensitive  to  heat  or 
cold,  even  though  the  increased  sensitiveness  may  be  of  short 
duration.  From  this  slight  degree  of  hyperemia  there  may 
occur  paroxysms  of  pain  which  will  last  for  some  minutes,  or 
even  half  an  hour  or  more,  and  then  subside.  Occasional  cases 
occur  in  which  there  is  more  or  less  pain  almost  continually,  and 
changes  of  temperature  of  three  or  four  degrees  are  sufficient  to 
cause  paroxysms  of  extreme  pain. 

All  cases  of  pain  which  may  be  induced  by  hot  or  cold 
applied  to  the  tooth  should  be  considered  as  hyperemia,  provided 
there  is  no  exposure  of  the  pulp  to  carious  dentin.  If  decay  has 
reached  the  pulp,  it  should  be  considered  as  an  inflamed  pulp. 

I  recall  a  case  in  which  a  patient  presented  with  an  acute 
abscess,  and  she  remembered  that  the  tooth  had  been  extremely 
sensitive  to  thermal  changes  for  a  few  weeks  after  it  was  filled. 
She  also  stated  that  the  tooth  had  since  been  perfectly  com- 
fortable until  the  day  or  two  before  the  abscess  developed.  My 
record  showed  that  I  had  placed  the  filling  in  this  tooth  eighteen 
years  previously,  and  there  is  little  doubt  but  that  the  pulp  died 
very  soon  afterward.  It  had  remained  during  the  intervening 
years  without  involvement  of  the  periapical  tissues. 

Sequels. 

As  the  paroxysms  of  pain  become  more  severe  or  of  longer 
duration,  some  of  the  arteries  are  generally  expanded,  while 


HYPEREMIA    OF    THE    DENTAL    PULP.  257 

other  arteries  and  the  veins  are  collapsed  to  make  room.  It  is 
but  one  more  step  to  a  complete  stagnation  of  the  circulation  in 
the  pulp,  and  the  death  of  the  organ.     This  is  called  infarction. 

When  a  pulp  dies  of  hyperemia,  there  occurs  a  solution  of  the 
red  corpuscles  which  have  escaped  into  the  tissues.  This  color- 
ing matter  penetrates  into  the  dentin,  often  causing  a  marked 
discoloration  of  the  tooth,  which  is  verj^  difficult  to  bleach.  This 
discoloration  may  be  compared  to  the  discoloration  of  the  soft 
tissue  which  occurs  about  a  contused  wound.  In  the  latter, 
however,  the  color  is  gradually  changed  to  normal  by  the  circula- 
tion, but  a  similar  change  can  not  occur  in  the  tooth.  When  the 
death  can  be  immediately  discovered  and  the  pulp  removed,  the 
discoloration  may  be  prevented. 

Cases  which  terminate  in  the  death  of  the  pulp  often  result 
in  the  formation  of  either  an  acute  or  chronic  alveolar  abscess. 
When  the  pulp  dies,  the  patient  is  free  from  pain  and  no  further 
thought  is  given  to  the  tooth,  the  supposition  being  that  it  is  all 
right.  The  case  may  go  for  years  without  involvement  of  the 
periapical  tissues  until  possibly,  without  apparent  cause,  an  acute 
abscess  suddenly  develops,  or  a  chronic  abscess  may  develop  and 
gradually  destroy  the  bone  about  the  end  of  the  root. 


258  SPECIAL   DENTAL    PATHOLOGY. 


INFLAMMATION  OF  THE  DENTAL  PULP 

ILLUSTRATIONS:    FIGURES  308-315. 

The  pulp  becomes  inflamed  from  injuries  or  infections  the 
same  as  other  tissues  of  the  body,  but  has  not  the  same  powers 
of  recover}^  It  also  suppurates  quite  commonly  when  it  becomes 
inflamed.  This  suppuration  is  identical  with  suppurations  in 
other  tissues  of  the  body,  but  the  results  of  suppuration  are 
especially  destructive  in  this  small  bit  of  tissue,  the  more  so 
because  of  its  gelatinous  type  and  its  low  degree  of  the  power  of 
resistance. 

Etiology. 

The  most  common  cause  of  inflammation  of  the  pulp  is 
dental  caries  which,  has  progressed  sufficiently  to  involve  the 
pulp  or  to  expose  it  by  laying  it  bare. 

In  decay  of  the  teeth  the  dentin  may  be  softened  about  a 
portion  of  the  pulp  tissue  without  the  complete  destruction  of 
the  dentin  covering  the  pulp.  It  has  been  a  favorite  hypothesis 
among  dentists  that  such  softened  dentin  could  act  as  a  protec- 
tion to  the  pulp,  and  it  has  even  been  incorrectly  held  that  it 
would  become  hardened  again.  After  medication,  which  has 
taken  a  pretty  wide  range  from  the  strongest  to  the  mildest  anti- 
septics, a  nonconductor  has  been  placed  over  the  softened  den- 
tin; or  a  nonconductor  has  been  placed  over  it  without  other 
treatment.  I  have  followed  these  forms  of  treatment  very 
closely  with  records,  and  have  found  that  the  death  of  the  pulp 
has  generally  occurred  within  a  variable  time,  regardless  of  the 
treatment  employed.  This  has  been  so  general  that  I  have 
repeatedly  urged  that  the  last  bit  of  carious  dentin  should  be 
removed,  and  then  the  pulp  handled  as  might  seem  best. 

In  caries  of  the  teeth,  the  acid-producing  micro-organisms 
grow  into  the  dentinal  tubules  after  an  opening  has  been  made 
through  the  enamel.  The  acid  always  penetrates  the  tubules  of 
the  dentin  in  advance  of  the  growth  of  the  organisms,  both 
following  the  length  of  the  tubules  progressively.  The  dentin 
is  thus  penetrated,  until  the  pulp  is  finally  reached.  The  acid 
softens  the  dentin,  and  these  organisms  and  others,  including 
those  which  produce  inflammation  and  suppuration,  and  many 


INFLAMMATION    OF    THE    DENTAL    PULP.  259 

saprophytes*,  which  follow  the  progress  of  the  organisms  pro- 
ducing decay,  all  together  melt  down  and  destroy  the  softened 
tissue.  Therefore,  very  soon  after  the  softening  of  the  dentin 
has  reached  the  pnlp,  micro-organisms  of  various  sorts  may 
come  in  contact  with  the  pulp  tissue  and  infect  it.  This  has  been 
universal  in  the  tissues  I  have  prepared  and  brought  under  the 
microscope. 

Inflammation  of  the  pulp  may  result  from  its  exposure  in 
cavity  preparation.  When  the  excavating  is  done  without  suffi- 
cient regard  for  the  depth  of  decay,  or  for  the  form  of  the  pro- 
trusions of  the  horns  of  the  pulp  into  the  crowns  of  the  teeth, 
particularly  in  the  bicuspids  and  molars,  many  exposures  will 
result.  Generally  a  touch  of  any  part  of  the  pulp  in  excavating 
will  be  sufficient  to  set  up  an  inflammatory  movement  which  will 
cause  its  death. 

The  pulp  may  be  exposed  by  breakage  of  the  tooth,  or  other 
violence  which  crushes  or  destroys  such  portions  of  the  hard 
structure  of  the  tooth  as  will  lay  the  pulp  bare.  Occasional 
cases  occur  in  which  the  pulp  dies  as  a  result  of  a  blow  upon  the 
tooth  which  does  not  fracture  the  tooth.  The  pulp  evidently 
dies  as  a  result  of  the  injury  to  the  tissues  about  the  apex  of  the 
root.     This  occurs  most  frequently  in  the  incisor  region. 

Pathological  changes. 

The  result  of  inflammation  of  the  pulp  in  the  tooth  of  an 
adult  is  practically  always  the  death  of  the  organ.  This  has 
been  referred  to  in  a  previous  chapter  in  considering  the  healing 
powers  of  the  pulp. 

Generally  in  those  cases  in  which  decay  has  reached  the 
pulp,  but  it  is  still  covered  by  softened  dentin,  the  pulp,  upon 
microscopic  examination,  will  show  a  small  area  of  inflamma- 
tion within  the  part  of  its  tissue.  (See  Figures  308  to  312.) 
This  area  is  particularly  liable  to  be  small  if  no  symptoms  have 
occurred.  In  cases  in  which  symptoms  have  occurred,  the  area 
of  inflammation  will  be  found  broader  as  the  rule,  although,  as 
already  stated,  the  symptoms  are  generally  the  same  as  those  in 
hyperemia.  In  many  of  the  eases  in  which  very  considerable 
pain  had  been  invoked  during  the  inflammatory  process,  I  have 
found  in  the  pulp  tissue  small  abscesses,  or  abscessed  cavities, 
which  seemed  to  determine  verj^  great  exacerbations  of  pain. 

*  I  have  used  the  word  saprophytes  to  designate  a  class  of  micro-organisms  which 
will  not  grow  in  living  tissue,  but  may  grow  close  about  diseased  parts  and  effect  the 
decomposition  of  pus  or  other  decomposible  m:iterial,  producing  products  which  may 
or  may  not  be  poisonous  to  the  living  tissues. 


260  SPECIAL   DENTAL   PATHOLOGY. 

(See  Figure  313.)  However,  in  a  few  rather  widely  inflamed 
pulps,  giving  the  same  symptoms,  there  was  no  evidence  of 
abscesses  when  the  pulp  was  examined  microscopically.  This 
makes  the  general  correctness  of  the  subjective  sign  of  abscess 
formation  uncertain. 

Some  years  ago  I  had  the  opportunity  to  study  one  case  of 
suppuration  of  the  pulp;  the  patient  refusing  to  have  it 
removed.  In  this  case,  abscess  after  abscess  occurred  in  the 
bulb  of  the  tooth,  which  was  a  lower  molar  and  easy  of  access. 
It  is  interesting  to  note  the  relation  of  pain  to  this  abscess 
formation.  In  the  first  instance  of  lancing  the  abscess,  the 
patient  refused  radical  treatment,  although  he  was  in  great  pain. 
The  point  of  a  very  sharp  eye-knife  was  passed  into  it  and  a 
goodly  drop  of  pus  was  discharged.  This  rendered  the  patient 
comfortable  at  once.  In  about  a  week  he  was  again  suffering 
and  the  same  process  was  repeated  with  the  same  result.  This 
was  repeated  five  or  six  times  within  about  as  many  weeks.  The 
abscesses  always  caused  intense  pain  which  was  relieved  by  the 
discharge  of  the  pus.  But  this  pulp  was  losing  tissue  continu- 
ally during  this  time,  until  there  was  not  very  much  of  the 
bulbous  portion  left.  Finally  I  had  to  reach  into  one  of  the 
roots  to  discharge  an  abscess  occurring  in  that  portion  of  the 
pulp.  This  might  have  gone  farther,  but  the  patient  finally 
accepted  extirpation  of  the  pulp  and  the  ordinary"  root  treatment. 

This  I  regard  as  a  very  interesting  observation,  and  shows 
that  great  pain  in  the  pulp  of  a  tooth  may  be  due  to  abscess 
formation.  It  will  explain  some  cases  which  are  very  difficult  to 
understand  otherwise.  For  instance,  one  may  have  suffered 
very  severe  pain  from  the  teeth,  and  finally  that  pain  may  have 
ceased  almost  instantly.  It  may  recur  later  with  a  similar 
paroxysm  lasting  possibly  several  days,  and  then  pass  away. 
This  seems  to  represent  the  f oiTQation  and  discharge  of  pus  from 
these  tiny  abscesses  in  the  pulp  tissue.  In  my  cuttings  of  pulps 
I  have  found  a  considerable  number  of  these  abscessed  cavities, 
and  this  pathology  and  symptomatology  coming  together  would 
be  very  interesting  if  we  could  make  any  especial  use  of  them  in 
directing  treatment ;  but  as  these  pulps  will  die  anyway,  we  are 
not  able  to  make  practical  use  of  the  information  gained. 

Figure  312  is  from  a  case  of  suppuration  of  a  pulp  showing 
hollowing  out  of  the  central  portion.  Such  cases  are  not  very 
frequent,  yet  the  tendency  of  the  suppuration  to  attack  most 
prominently  the  central  gelatinous  portion  of  the  pulp  has 
become  evident. 


inflammation  of  the  dental  pulp.  261 

Diagnosis. 

Pulp  exposed  to  caeious  dentin.  The  one  dctermiuing  sign 
that  inflammation  has  begun  in  the  pulp  is  the  finding,  by  careful 
removal  of  all  decay,  that  the  pulp  has  been  exposed  to  carious 
dentin.  If  it  has,  it  should  be  considered  an  inflamed  pulp, 
whether  it  has  given  any  symptoms  or  not,  and  treated  accord- 
ingly. If,  however,  it  is  still  covered  by  hard  dentin,  it  should 
not  be  regarded  as  an  inflamed  pulp,  no  matter  what  the  sj'^mp- 
toms  have  been.  I  give  this  as  the  most  certain  way  to  deter- 
mine clinically  between  inflammation  and  hyperemia  of  the  pulp 
that  I  have  yet  been  able  to  make  out. 

Pain.  Pain  is  a  very  usual  symptom  of  inflammation  of  the 
pulp.  In  very  many  cases,  the  progress  of  the  inflammation  is 
very  quiet,  producing  but  little  pain.  It  is  not  uncommon  for 
pulps  to  die  from  inflammation  and  suppuration,  giving  no 
symptom.  This  may  occur  whether  the  pulp  chamber  is  open  or 
closed.  However,  paroxysms  of  pain  are  liable  to  be  induced  by 
thermal  changes,  giving  the  symptoms  of  hyperemia.  In  every 
case  of  apparent  hyperemia,  it  must  be  determined  that  the 
decay  has  not  reached  the  pulp.  This  is  necessary  to  make  a 
proper  diagnosis,  which  will  determine  the  course  of  treatment. 

In  some  cases,  the  pain  may  be  so  intense  and  of  such  con- 
tinuous duration  as  to  finally  almost  rob  the  patient  of  reason. 
In  some  rare  cases  I  have  seen  the  most  pronounced  examples 
of  this.     I  will  relate  one  case. 

A  woman  was  brought  to  the  clinic  of  Northwestern  Uni- 
versity Dental  School  a  number  of  years  ago,  to  consult  me  in 
regard  to  persistent  pain.  In  this  case  the  patient  had  applied 
to  her  dentist  with  pain  which  she  located  in  the  second  bicuspid 
in  the  lower  jaw.  The  dentist  found  a  cavity  in  the  mesial 
surface  of  that  tooth,  which  he  prepared,  and  finding  no  exposure 
of  the  pulp,  he  placed  a  gutta-percha  filling.  The  pain,  instead 
of  being  relieved,  became  worse.  At  the  next  sitting  he  exposed 
the  pulp  and  removed  it,  using  cocain  anesthesia,  and  placed  in  a 
dressing.  The  pain  continued  and  became  very  excruciating. 
He  waited  several  days,  during  which  the  patient  suffered  con- 
tinuously, and  then  brought  her  to  me  in  consultation. 

The  patient  was  very  weak  and  nervous  because  of  loss  of 
sleep  and  continual  suffering.  I  found  a  cavitv^  in  the  distal 
surface  of  the  first  bicuspid  with  the  gutta-percha  filling  in  the 
mesial  surface  of  the  second  bicuspid  lying  right  against  it. 
Cutting  away  the  gutta-percha  filling  so  as  to  see  the  distal  sur- 
face of  the  first  bicuspid  clearly,  I  broke  away  the  overhanging 

as 


262  SPECIAL    DENTAL    PATHOLOGY. 

enamel  with  a  suitable  instrument,  exposing  the  extent  of  the 
cavity.  This  tooth  was  not  sore  to  the  touch,  but  in  opening  the 
cavity  I  caused  a  great  increase  in  the  pain,  even  though  I  had 
not  touched  the  pulp  with  my  instrument.  I  had,  however, 
forced  some  debris  into  the  cavity  and  this  pressed  on  the  pulp. 

In  view  of  the  fact  that  this  patient  had  suffered  so  long  and 
so  severely,  and  was  still  suffering  intense  pain  whether  any 
operation  was  proceeding  or  not,  I  determined  that  the  best 
course  was  to  relieve  the  pain  then  and  there  at  all  hazards. 
When  the  cavity  was  opened  sufficiently,  I  selected  a  broach,  and 
passing  it  down  carefully  along  the  wall  of  the  pulp  chamber,  I 
thrust  it  to  the  apical  end  of  the  canal,  and  quickly  withdrew  it 
with  a  little  twist,  luckily  bringing  away  the  whole  pulp.  I  at 
once  prepared  the  cavity,  laid  in  a  dressing,  and  sealed  it  with 
gutta-percha.  Before  I  had  finished,  the  patient  was  asleep. 
Some  of  the  young  men  carried  her  to  a  bed  without  awaken- 
ing her,  and  she  slept  about  five  hours.  After  she  awoke  she 
expressed  herself  as  being  free  from  pain,  and  the  pain  did  not 
recur. 

This  case  gives  as  good  an  idea  of  the  intensity  of  pain 
which  may  be  induced  by  inflammation  of  the  pulp,  as  any  that 
I  have  been  able  to  select  from  my  practice. 

Chronic  inflammation  of  the  pulp.  Chronic  inflamma- 
tion of  the  pulp  occurs  in  many  cases,  though  they  are  exceptions 
to  the  most  general  rule.  The  pulp  will  sometimes  become 
exposed  and  give  no  sign  in  the  way  of  pain  except  when  pressed 
upon  by  something  forced  into  the  cavity  in  chewing  food.  The 
l^atient  learns  to  avoid  such  injuries,  and  goes  on  with  compara- 
tive comfort,  chewing  his  food  on  the  other  side  of  the  mouth 
until,  after  some  months  or  years  possibly,  the  pulp  will  die 
either  as  a  result  of  the  chronic  inflammation  or  an  acute  infec- 
tion. Such  cases  are  usually  followed  by  alveolar  abscess  unless 
they  have  prompt  attention. 

Sometimes  cases  persist  in  a  state  of  chronic  inflammation 
for  several  years.  Such  cases  do  not  respond  to  other  than 
]^alliative  treatment.  The  attempt  to  cover  them  over  with  any 
kind  of  a  capping  generally  results  in  the  speedy  death  of  the 
pulp.  Some  exceptions  to  this  rule  are  found,  but  they  are  not 
sufficiently  frequent  to  be  entitled  to  consideration.  Figure  314 
is  from  a  case  of  chronic  inflammation  of  the  pulp. 

Hypertrophy  of  the  pulp. 

Hypertrophy  of  the  i>u]j)  occurs  in  n  few  cases  of  chronic 


INFLAMMATION    OF    THE    DENTAL    PULP.  263 

inflammation  of  the  pul]),  in  which  a  considerable  cavity  in  tlie 
tooth  has  occurred,  making  a  broad  exposure  of  the  organ.  Its 
tissues  will  swell  and  be  forced  out  into  the  cavity  of  decay 
through  the  opening  into  the  pulp  chamber.  This  growth  of 
tissue  may  enlarge  until  it  entirely  fills  the  carious  cavity.  (See 
Figure  315.)  In  cases  in  which  the  condition  is  maintained  for 
some  time,  saprophytic  micro-organisms  will  decompose  and 
remove  all  the  carious  dentin  around  the  portion  of  the  pulp 
which  is  extruded  into  the  cavity  of  decay. 

Sometimes  I  have  found  this  so  complete  that  the  dentin 
walls  were  left  very  hard  and  firm,  the  softened  portion  having 
been  digested  and  removed  by  the  saprophytic  organisms.  This 
occurs  occasionally  in  large  cavities  that  are  widely  open,  but 
in  which  decay  seems  to  have  ceased  because  of  the  interference 
of  saprophytic  organisms,  the  growth  of  which  was  incom- 
patible with  the  growth  of  the  caries  fungus.  The  softened  por- 
tion of  the  dentin  is  removed,  leaving  hard,  blackened  cavity 
walls.    The  decay  is  stopped,  at  least  temporarily. 

Diagnosis.  The  diagnosis  of  hypertrophy  of  the  pulp  is 
very  simple,  for  the  cavity  is  filled  more  or  less  completely  with 
a  reddened,  fleshy  material,  with  which  the  opposing  teeth  often 
come  in  contact.  It  is  easily  seen,  whether  or  not  it  completely 
fills  the  cavity.  It  often  happens  that  the  portion  of  the  pulp 
exposed  in  this  way  becomes  covered  with  epithelium  which  has 
been  transplanted  from  the  neighboring  gingivae  and  grows 
there  the  same  as  will  epithelium  planted  upon  a  granulating 
surface. 

This  hypertrophied  tissue  is  generally  not  painful,  except 
when  the  patient  bites  something  down  upon  it.  One  soon  learns 
to  avoid  this,  chewing  mostly  on  the  other  side  of  the  mouth. 
Therefore  this  unused  side  is  apt  to  become  unclean,  and  the 
gums  more  or  less  reddened  and  inflamed. 

In  the  further  diagnosis  of  this  condition  and  the  differen- 
tia] determination  from  a  growth  of  the  septal  gingiva  which 
may  fill  a  carious  cavity  and  have  precisely  the  same  appear- 
nnco  as  this  growth  of  pulp  tissue,  one  may  pass  a  thin,  flat 
instrument  into  the  subgingival  space,  close  to  the  gingival  line, 
and  move  it  toward  the  occlusal,  keeping  it  against  the  proximal 
surface  of  the  tooth.  If  it  may  be  passed  out  to  the  occlusal 
readily,  without  displacing  or  lifting  any  of  the  tissue,  the 
growth  is  from  the  pulp.  If  the  tissue  is  caught  and  lifted,  the 
growth  is  from  the  septal  tissue  nnd  not  from  the  pulp,  for  in 
that  case  the  septal  tissue  protrudes  into  the  cavity  of  decay. 


264  SPECIAL,    DE^'TAL   PATHOLOGY. 

Treatment.  If  it  is  found  to  be  a  protrusion  of  pulp  tissue, 
a  very  broad  spoon  excavator,  the  edge  of  which  is  sharp,  shouUl 
be  passed  down  between  the  cavity  wall  and  the  growth,  and 
then  swept  across  under  the  tissue,  keeping  it  close  against  the 
walls  of  the  cavity,  cutting  the  whole  mass  loose  from  that  por- 
tion of  the  pulp  within  the  pulp  chamber.  If  this  stroke  is 
successful,  the  growth  will  all  be  removed.  If  not,  the  stroke 
will  have  to  be  repeated  to  loosen  the  remaining  portion. 

This  cutting  causes  a  slight  pain  and  a  profuse  hemorrhage. 
The  hemorrhage  will  stop  in  a  few  minutes  and  the  blood  may 
be  washed  away  and  the  cavity  inspected.  The  stump  of  the 
pulp  remaining  in  the  pulp  chamber  may  then  be  treated  for  its 
removal  the  same  as  any  other  exposed  pulp.  It  may  be  desen- 
sitized by  cocain  in  the  usual  way,  or  destroyed  by  arsenic. 
Neither  of  these  will  act  quite  so  promptly  on  such  a  pulp  as 
upon  one  which  has  not  been  so  long  in  a  state  of  inflammation, 
but  they  do  not  generally  give  especial  difficulty. 

If  the  examination  shows  the  growth  within  the  cavity  to 
be  from  the  septal  tissue,  an  ordinar}^  silk  ligature  may  be  car- 
ried through  the  interproximal  space  to  the  gingival  of  it,  and 
the  ends  brought  up  around  the  growth.  The  hypertrophied 
tissue  may  be  lifted  out  of  the  cavity,  and  the  ligature  should 
then  be  drawn  hard  against  the  enamel  of  the  next  tooth  and 
the  hj'pertrophied  tissue  cut  away  with  a  single  quick  pull. 
This  will  partly  cut  and  partly  tear  away  the  growth  of  tissue, 
which  has  filled  the  cavity.  As  this  is  done,  the  effort  should  be 
made  to  leave  about  the  normal  amount  of  septal  tissue.  One 
should  be  careful  to  so  place  the  silk  ligature  that  it  will  not 
bring  away  the  entire  septal  tissue,  as  I  have  seen  done  some- 
times. This  would  create  an  injury  which  would  never  fully 
recover,  because  the  septal  tissue  would  be  too  short  to  fill  the 
space  properly. 

The  actual  cautery  may  be  employed  to  remove  either  the 
hypertrophy  of  the  pulp  or  of  the  septal  tissue.  If  the  wire  is 
white  hot,  it  will  cause  no  pain,  and  the  hemorrhage  will  be  less 
than  by  the  other  method  given. 

These  growths  have  no  malignancy.  In  cases  in  which  there 
is  a  hypertrophy  of  the  pulp,  the  pulp  itself  should,  of  course, 
be  removed.  The  growth  of  septal  tissue  into  such  a  cavity  is 
caused  by  the  roughened  walls  of  the  cavity,  and  when  the  sur- 
face of  the  tooth  is  made  smooth  by  a  filling,  there  is  no  tendency 
to  a  regrowth. 


CALCIFICATIONS    OF    THE    DENTAL    PULP.  265 

CALCIFICATIONS  IN   THE  PULP  CHAMBER  AND 
THEIR  EFFECTS  UPON  THE  PULP  TISSUE 

ILLUSTRATIONS:    FIGURES  316-341. 

In  my  writing  in  the  American  System  of  Dentistry,  I  gave 
very  accurate  descriptions  of  a  large  variety  of  the  calcifications 
found  in  the  pulp  chamber,  with  illustrations,  including  those 
which  grow  upon  the  walls  of  the  chamber  and  those  which  grow 
within  the  tissue  of  the  pulp  separately  from  the  walls.  As  a 
description  of  the  formations,  that  writing  was  quite  sufficient. 
A  number  of  forms  were  described  which  are  very  rare.  We  are 
now  more  interested  in  the  effect  of  such  growths  upon  the  pulp 
and  the  conditions  under  which  we  may  exj^ect  to  find  them,  than 
in  the  varieties  of  growths  found. 

Classification. 

I  will,  therefore,  in  this  writing,  limit  myself  closely  to  the 
effect  of  these  growths  upon  the  tissue  of  the  pulp,  classifying 
them  into  a  few  specific  forms.  A  limited  number  of  these,  if 
not  excessive  in  their  growth,  are  beneficent  in  their  effect,  but 
nearly  all  of  them  are  pernicious.  They  must  be  regarded  as 
pathological.  The  forms,  which  I  need  mention,  may  be  divided 
into  two  classes,  and  each  of  these  may  be  again  divided  for 
identification : 
Calcifications  attached  to  the  walls  of  the  pulp  chamber. 

1.  Growths  upon  the  walls  of  the  pulp  chamber  in  which 
the  tubules  are  continuous  with  those  of  the  ordinary  dentin  — 
secondary  dentin. 

2.  Growths  continuous  upon  the  walls  of  the  pulp  chamber ; 
beginning  as  secondary  dentin,  but  in  which  the  dentinal  tubules 
progressively  disappear  and  the  growth  continues  as  a  non- 
tubular,  clear  calcification. 

3.  Growths  attached  to  the  internal  wall  of  the  pulp  cham- 
ber, which  are  nontubular,  clear  calcifications  from  the  begin- 
ning. In  any  of  these  calco-spherites,  or  small  nodules,  which 
have  previously  formed  free  in  the  tissues  of  the  pulp  may  occa- 
sionally be  included. 

Calcifications  growing  free  in  the  tissues  of  the  pulp,  unat- 
tached to  the  walls  of  the  pulp  chamber. 
1.     Nodular  formations,  growing  free  in  the  tissues  of  the 
pulp,  usually  confined  to  the  bulb  of  the  ]nilp.     These  may  or 
may  not  contain  calco-spherites. 


266  SPECIAL   DENTAL   PATHOLOGY. 

2.  Fusiform  calcifications,  occurring  in  the  root  portion  of 
the  pulp.  These  are  usually  disposed  with  their  length  parallel 
to  the  length  of  the  canal. 

3.  Jointed  calcifications  in  the  root  portion  of  the  pulp. 

4.  More  extensive  growths  of  calcific  materials,  which  fill 
up  the  pulp  chamber,  sometimes  including  more  or  less  of  the 
contents  of  the  canals,  especially  in  the  molars. 

Personal  investigations. 

I  have  made  a  wide  pursuit  of  this  subject  for  a  number 
of  5^ears,  examining  not  only  teeth  which  I  was  able  to  find  in 
my  own  practice,  but  numbers  which  were  sent  to  me  by  others, 
AVith  each  of  these  I  was  furnished  a  written  description  of  the 
case.  These  were  very  largely  teeth  extracted  in  preparing 
mouths  to  receive  artificial  teeth,  and  often  comprised  from  two 
or  three  to  a  dozen  or  more  from  the  same  mouth.  Some  were 
teeth  extracted  for  other  reasons,  from  persons  of  widely  differ- 
ent ages.  These  teeth  were  cracked  open,  the  pulp  lifted  from 
its  bed,  and  some  of  them  were  examined  after  decalcification, 
and  sections  were  made  for  microscopic  study.  A  number  of 
pulps,  which  presented  many  calcifications,  were  simply  spread 
as  well  as  possible  upon  a  glass  slide  and  a  cover-glass  laid  on 
for  observation  with  the  binocular  microscope,  using  low  |)owers. 
In  this  manner  of  examination  good  views  could  be  obtained  of 
the  character  of  the  growths.  I  secured  a  very  large  variety  of 
cases  within  the  years  which  I  devoted  to  this  study.  Practically 
all  of  these  may  be  said  to  fall  within  the  range  of  the  seven 
groups  named  above. 

This  classification  does  not  include  all  of  the  forms  which 
may  be  seen.  Each  specimen  presents  some  special  points  of  dif- 
ference, no  two  being  exactly  alike.  The  classification  of  a  great 
variety  of  forms  is  of  little  value  to  the  practitioner,  since 
one  generally  can  not  make  a  diagnosis  except  by  finding  them 
after  the  pulp  chamber  has  been  opened.  Some  of  the  conditions 
can  not  be  definitely  differentiated  without  a  microscopical 
examination  of  the  pulp  tissue. 

In  my  examinations  of  these  teeth,  reference  to  the  history 
of  the  patient  accompanied  the  particular  tooth,  and  symptoms 
v/hich  might  indicate  calcification  of  the  pulp  were  sought  for 
(ontinually.  Some  of  these  were  cases  of  abrasion  and  erosion, 
in  wliich  the  filling  up  of  the  pulp  chamber  with  hard  material 
was  sufficiently  evident  to  the  naked  eye.  There  were  also  cases 
in  which  the  teeth  had  l)een  sensitive  for  a  time  and  the  sensi- 


Fig.  ?,]Ck 


Fig    317. 


Fi(i.  'MS. 


FlOS.  .31G  AND  :!17.  Tcrlli  fr.piii  tlir  s.-iiiif  iiiniitli,  slidwiiiy  en. si. Ill  wlii.-li  li.-nl  cut 
so  noarly  Ihrongli  one  tlial  |i;irl  oT  tlic  crown  li;ul  Im-.iUc;i  nil'.  In  Inilli  llic  1'. inner 
positioiiof  the  |tiil|)  chanihcr  had  lu'i'ii  cut  tlii()M>;li,  luil  li:i<l  l.trn  jncv  ionsly  lilli'd  witli 
soeondary  dentin  and  llio  |inl|is  were  not  ('X|)osc.l.  Sincinicns  troni  Nortlnvcstcrn 
University  Dental    Museum. 

Fig.  ;il8.  Secondary  dentin  in  case  of  extensive  abrasion.  The  position  of  the 
former  pulp  chamber  has  been  reached  bv  the  wear,  but  it  had  lieen  previously  closed 
over  by  the  building  of  secondary  dentin.  Specimen  prepared  by  Dr.  H.  A.  Potts. 
Photomicrograph  by  Dr.  F.  B.  Noyes. 


*a6 


^^^\.^ 


*-i 


//.:ra 


■  mm 


UMi. 


,-  V: 


Fig.  319. 


Fig.  319.     Secondary  dentin:     a,  Margin  of  primary  dentin,  showing  a  few  of 
the  tubules  continuing  into  secondary  dentin,     p.  Pulp  chamber.     Noyes. 


Fig.  320. 


Fig.    320.      Secondary   dentin,   magnified   sufficiently   to    show   the    difference    in 

?  Sar\"deTtin  ^^7  V'^^'^  a  Abraded  surface  of 'crown,  b.  Se:ond.^rde  tin 
c,  i-rimary  dentin,  d,  Junction  of  primary  with  secondary  dentin  e  Reimin«  nf 
pulp  tissue,     f,  Small  oval  masses  of  calcific  material.  o,  Kemains  ot 


Fig.  321. 


Fig.  322. 


Fig.  '.'>2\.  I)iiij;r;iiii  slmuini^  (l(|)()sit  of  sccdinlji  iv  dent  in.  wliicli  wiis  dcsfriljotl  in 
the  American  System  of  Dentistry,  Vol.  I,  pajjc  SG9,  Fi^.  464,  as  resulting  from  earies 
of  an  incisor.  Caries  at  a,  and  secondary  dentin  at  1).  In  tiie  circle  the  strncture  of 
the  secondary  dentin  is  shown,  a,  Pulp  chamber,  b,  b,  Secondary  dentin,  e.  Primary 
dentin.  It  will  be  noticed  that  the  dentinal  luix's  in  tlie  secondary  dentin  gradually 
di.sappear,  giving  place  to  a  clear  calcification. 

Fig.  322.  Diagram  showing  secondary  dentin,  which  was  described  in  the  .Amer- 
ican System  of  Dentistry,  Vol.  I,  page  S70,  Fig.  4(i5.  as  resulting  from  irritation  of  the 
dentinal  filtrils  by  caries.  Decay  in  the  labial  surface,  a,  and  a  deposit  of  secondary 
lientin,  b.  The  ])oint  from  which  the  enlargeil  drawing  is  taken  is  shown  by  c. 
In  i^he  circle  the  tissue  of  the  secondary  deposit  is  shown:  a,  Primary  dentin, 
b.  Secondary  ilentin.  c.  Seems  to  be  a  blood  vessel  that  has  become  calcified,  d.  An 
irregular  fault  having  some  resemblance  to  tlie  lacuna?  of  bone,  e,  Pulp  chamber. 
It  will  be  noted  that  there  are  irregular  deposits  of  granular  matter  in  the  siibstance 
of  the  secondarv   d'ntin.   ;iiid    th;it   the   tnbulcs   winil   abdut    them. 


Fig.  323.  SocoiKlary  dentin,  filling;  llio  pnip  eliainpor  in  case  of  abrasion  of  a 
cuspid  tooth:  a,  Portion  lost  by  abrasion,  c,  Abraded  surface,  d.  Secondary  dentin, 
filling  a  portion  of  the  pulj)  chanilx-r  and  acting  as  a  i)rotection  to  the  juilp.  e, 
Slender  point  of  the  jnilp;  irreyuhir  dei)osits  are  seen  on  Ww  wniis  of  the  iniii) 
chainbrr.  as  at  f.  g,  CyMiidrical  calcifications  in  the  root  portion  nf  th.'  pnl].  .•lianil)er. 
Fui  :;-2\.  I.'eductioii  of  liie  si/.r  of  the  jMilp  ,-li;nnlHT  i^v  .|.'|insit  of  src.ndary 
dentin  as  a  result  of  at)rasion.  In  the  larger  drawing  tii.'  tissue  of  the  secomlary 
deposit  is  shown,  a,  a,  a.  Outline  of  the  original  pulp  chamber,  from  which  the 
secondary  growth  has  begun;  in  th.'  root  wise  pcutir.n  there  aj-pears  a  second  hnc 
of  beginning,     b.  (Ilobidar   formation   of  dnilin.     .-.    Irr.'guhir  crystallin,'  .lrp(,sit. 


[I'll 


Ml 


'SmFm 


Wilm 


^■mr~ci 


Fig.  325. 


Fig.  .■!26. 


Fig.  325.  Outline  of  incisor,  showing  a  narrowing  of  tho  root  canal  at  b  by  a 
ijeposit  of  secondary  dentin.  In  the  circle  tlie  structure  of  tlie  formation  is  shown: 
a,  Primary  dentin,  b,  Line  of  the  beginning  of  a  growth  of  secondary  dentin. 
c,  Secondary  dentin,  d.  Layer  of  granular  matter,  i.  Irregular  crystalline  deposits, 
h,  The  pulp  chamber. 

Fig.  326.  Outline  of  abraded  incism-.  with  point  of  pulp  chaiiilx'r  (a)  closed  by 
secondary  dentin,  b,  Points  out  a  narrowing  of  tlie  root  canal  by  a  deposit  of 
secondary  dentin.  Tn  tlie  circle  the  structure  of  the  formation  is  shown:  a,  Pulp 
i-hamber.  b.  Calcific  m;iterial.  c.  Layer  of  very  small  calco-splierites.  d,  Primary 
dentin. 


Fig.  327, 


Fig.  328. 


Fig.  329. 


Fig.  327.  A  t  nuisvcrsc  scctit.ii  of  ;i  nxit.  slu.wiii^  lli.'  iciluctioii  in  tlif  size  of 
tho  pulp  Jind   formation  of  sccoiulary  dentin.     \<tii<s. 

Fig.  328.  A  central  incisor  showin^r  cxlensixc  ahnision.  'I'lic  pulp  is  all  cali'ihcl 
except  a  mere  shred  tliat  shows  as  a  white  line. 

Fig.  329.  A  central  incisor,  the  greater  jiart  of  the  crown  of  which  is  worn 
away.     The  pulp  is  cnniplclcly  calcified   far  into  thf  root. 


■^^.,^\^ 


Vi 


.?^r^ 


^^^'^^^^^^^r^^ 


Fig.  330. 


Fig.  330.  Atrophy  of  tlu'  odontoblasts  in  eoiinootion  with  the  building  of 
secondary  dentin,      (('onipjin'  witli    Fiyiire  291.) 

Fig.  331.  Atrophy  of  the  odontoblasts:  a.  Odoiitulilasts  that  have  taken  the 
stain  in  an  irregular  manner.  There  is  also  a  prculiar  sariatioii  in  their  size.  Some 
vacuolations  appear  in  the  tissue. 


CALCIFICATIONS   OF    THE    DENTAL   PULP.  267 

tiveness  had  disappeared;  other  cases  which  were  still  sensitive 
at  the  time  of  extraction,  in  which  abrasion  had  proceeded  only 
so  far  as  to  slightly  expose  the  dentin.  Tlie  examination  included 
cases  of  extensive  abrasion  and  erosion,  as  well  as  cases  which 
had  neither  abrasion  nor  erosion.  There  was  a  wide  variety  in 
the  ages  of  the  patients.  The  study  was  practically  exhaustive, 
and  as  I  look  back  upon  it,  much  of  it  seems  to  have  been  almost 
redundant. 

Calcifications  Attached  to  the  Walls  of  the  Pulp  Chamber. 

Under  this  heading  those  calcifications  generally  known  as 
secondary  dentin  will  be  described.  While  these  present  the 
differences  previously  enumerated,  they  are  so  intermingled 
that  it  seems  best  to  consider  them  together,  as  a  single  class, 
presenting  the  variations  denoted  in  the  groupings  we  have 
named.  In  the  examination  of  a  number  of  specimens,  we  will 
find  some  in  which  the  tubules  continue  regularly  into  the  new 
formation  —  true  secondary  dentin,  others  in  which  over  a 
space  the  tubules  are  missing  at  the  beginning  of  the  new 
growth.  (See  Figures  319,  320  and  321.)  This  may  occur  in 
small  patches.  In  another  case  quite  a  large  proportion  of  the 
new  growth  will  be  nontubular,  clear  calcification,  and  in  others 
complete  cutting  away  of  the  tubules  marks  the  beginning  of  the 
new  growth  throughout  its  attachment  to  the  original  dentin. 
The  cases  in  which  the  tubules  continue  across  into  the  new 
growth  are  very  much  more  frequent  than  those  which  begin 
with  a  clear  calcification. 

In  these  growths  more  or  less  reappearance  of  dentinal 
tubules  may  occur  in  irregular  forms,  but  they  rarely  straighten 
into  regular  dentin  formation;  much  will  be  simply  clear  calci- 
fication. These  generally  are  continuous  upon  the  walls  of  the 
pulp  chamber,  but  are  found  upon  the  walls  of  the  root  portion 
as  well.  The  growth  occurs  on  the  root-wise  portion  of  the 
double  and  triple  rooted  teeth,  or  in  the  floor  of  the  pulp  cham- 
ber, much  the  same  as  upon  the  occlusal  portion  and  axial  walls 
of  the  pulp  chamber.  In  some  growths,  which  begin  at  a  single 
point  upon  the  wall  of  the  pulp  chamber,  a  considerable  process 
of  almost  any  conceivable  form  may  grow  out  into  the  pulp  tis- 
sue. These  are  very  generally  clear  calcifications,  but  some- 
times they  show  a  confused  dentin  formation  with  the  dentinal 
tubules  twisted  among  eacli  other  in  vague  and  indefinite  forms. 

Etiology. 

These  calcifications  occur  under  many  conditions,  most  of 


268  SPECIAL    DENTAL    PATHOLOGY. 

which  are  abnormal.  They  occur  oftenest,  and  can  be  regularly 
found  in  cases  of  abrasion  and  of  erosion,  and  it  is  in  these  that 
their  causation  and  general  history  may  be  best  studied,  because 
they  present  a  large  variety  of  specimens,  from  those  which  are 
just  beginning  to  those  which  have  made  wide  progress.  Fig- 
ures 316  and  317  are  of  teeth  which  had  been  cut  through  the  posi- 
tion of  the  pulp  chambers  by  erosion.  Figures  318,  320,  328, 
329  and  several  other  illustrations  are  of  cases  of  abrasion. 
Something  of  the  same  character  of  secondary  dentin  occurs 
as  a  result  of  dental  caries,  if  the  decay  involves  a  considerable 
number  of  teeth  and  progresses  slowly,  keeping  the  fibrils  more 
or  less  exposed  to  irritation.  (See  Figures  321  and  322.)  If 
caries  progresses  with  what  we  may  call  normal  rapidity,  gener- 
ally no  deposit  of  secondary  dentin  will  occur.  Hence,  in  pre- 
paring cavities  for  filling  operations,  we  generally  do  not  find 
secondary  dentin  protecting  the  pulp. 

In  the  summing  up  of  the  results  of  my  observations,  it  has 
seemed  clear  that  extensive  abrasion  of  the  teeth  is  in  a  degree 
hereditary.  Therefore,  the  family  history  becomes  of  some 
importance,  particularly  in  the  matter  of  treatment. 

Nature  and  conditions  of  growth. 

The  new  growth  begins  upon  the  walls  of  the  dentin,  the 
tubules  running  across  the  line  of  the  beginning  new  growth, 
but  generally  with  enough  of  deviation  of  their  course,  or  a 
reduction  of  the  caliber  of  the  tubules  for  a  little  space,  to  show 
quite  distinctly  the  line  where  the  new  growth  began.  This 
regrowth  may  extend  a  considerable  distance  as  fairly  regular 
dentin.  Some  very  peculiar  features  are  discovered  in  extensive 
microscopic  studies  of  these  growths. 

Protection  for  pulp.  The  physiological  import  would 
seem  to  be  that  the  growth  of  secondary  dentin  is  a  response 
to  irritation  of  the  dentinal  fibrils,  and  has  a  definite  intention 
of  placing  the  soft  tissues  of  the  pulp  farther  from  the  source 
of  injury,  and  thus  protecting  it.  From  any  viewpoint  what- 
soever, this  idea  stands  out  prominenth^  For  instance,  when 
we  observe  a  tooth  that  has  a  number  of  facets  worn  into  the 
dentin  in  cup  shapes  in  the  position  of  the  cusps,  and  particu- 
larly in  those  cases  in  which  the  patient  has  had  much  pain  from 
these  in  biting  hard  substances,  because  of  the  sensitiveness  of 
the  exposed  dentin,  we  may  know  that  the  growth  of  this  second- 
ary dentin  is  starting. 

Calcification  more  extensive  as  abrasion  progresses.    The 


CALCIFICATIONS    OF    THE    DENTAL   PULP.  269 

secondary  dentin  becomes  more  extensive  as  the  abrasion  pro- 
gresses, and  finally  in  eases  in  which  most  of  the  crown  of  the 
tooth  has  been  worn  away,  a  clear  area  of  calcific  deposit  may  be 
seen  in  the  position  previously  occupied  by  the  pulp.  (See  Fig- 
ures 318,  323,  324.)  This  is  different  in  color  from  the  dentin 
surrounding  it;    usually  it  is  a  clearer  variety  of  calcification. 

Secondary  dentin  deposited  through  reflex  action  —  not 
A  local  formation.  The  most  general  idea  expressed  in  the 
literature  has  been  that  this  secondary  dentin  is  a  local  forma- 
tion, confined  mostly  to  the  protection  of  the  pulp  over  the  area 
which  is  threatened  by  the  injury  to  the  dentinal  fibrils.  My 
extensive  examinations  show  that  the  formation  occurs  reflexly 
from  an  impression  made  upon  nerve  centers  by  the  irritation 
of  the  dentinal  fibrils.  This  effect  is  general  to  the  teeth  of  the 
person,  and  not  localized  to  individual  teeth;  nor  is  it  localized 
over  the  regions  of  the  pulp  especially  threatened  by  the  irrita- 
tion of  its  fibrils.  That  is  to  say,  it  is  not  confined  to  local  parts 
of  the  individual  pulp  chambers,  nor  to  the  teeth  which  have 
been  worn,  but  occurs  also  in  those  teeth  that  may  have  escaped 
wear  as  a  result  of  the  previous  loss  of  teeth  of  the  opposite 
arch.  Such  teeth,  though  unworn,  will  show  the  calcification 
almost  precisely  the  same  as  those  which  are  worn. 

For  instance,  I  once  received  from  a  neighboring  dentist 
twelve  teeth  extracted  for  one  person,  among  which  there  were 
two  molars  that  were  unworn.  He  wrote  me  that  with  the  excep- 
tion of  the  wear  upon  the  teeth,  which  had  been  extensive,  the 
case  had  presented  no  abnormalities.  I  immediately  wrote  him, 
asking  how  it  happened  that  those  two  molars  had  escaped  wear. 
He  returned  the  reply  that  the  individual  had  had  the  molars 
from  the  opposite  jaw  extracted  many  years  before. 

I  examined  each  one  of  these  teeth  individually,  and  found 
that  the  secondary  dentin  had  started,  as  explained  in  the  begin- 
ning of  this  description,  as  a  fairly  regular  formation,  upon  the 
previously  existing  dentin;  but  it  had  begun  in  the  same  way 
and  had  proceeded  to  the  same  extent,  in  the  teeth  which  were 
unworn.  In  the  teeth  which  were  worn,  the  pulp  chambers,  even 
in  the  molars,  had  been  completely  obliterated  and  mostly  worn 
away.  The  puljj  chambers  of  the  unworn  teeth  were  obliterated  in 
the  same  way,  showing  that  the  effect  was  not  local  to  tlie  teeth 
worn,  but  involved  all  the  teeth  of  the  person.  This  I  have  found 
to  be  the  rule  in  all  of  these  extensive  calcifications  of  the  pulp. 

Tn  this  particular  case  the  wear  had  been  (]uite  a  little 
different  upon  different  teeth,  and  in  some  of  them  the  second- 


270  SPECIAL   DENTAL    TATHOLOGY. 

ary  deposit  had  not  all  been  worn  away,  wliicli  gave  me  the 
opportunity  to  examine  critically  the  secondary  dentin  on  whati 
had  been  the  floor  of  the  pulp  chamber.  The  fibrils  passed  fairly 
rec^ilarly  into  the  new  formation,  but  after  they  had  passed  into 
this  for  a  space,  they  began  to  drop  away  more  and  more  rapidly 
as  we  proceeded  deeper  into  it,  until  the  calcification  became 
clear  and  free  from  tubules.  It  is  this  part  of  the  calcification 
tiiat  is  seen  in  the  centers  of  pulp  cliambers  which  have  been 
filled  up,  and  have  afterward  been  abraded. 

In  comparing  these  with  teeth  in  which  the  formation  has 
not  been  so  extensive,  we  will  find  the  beginning  on  the  floor  to 
be  the  same  as  the  beginning  upon  the  occlusal  wall  of  the  pulp 
chamber;  the  calcification  occurring  upon  the  walls  of  all  yjarts 
of  the  pulp  chamber  together.  (See  Figure  324.)  This  could 
not  be  so  if  the  calcification  had  been  confined  to  the  region  of 
the  pulpal  ends  of  the  dentinal  fibrils  that  were  irritated  by  the 
abrasion,  proceeding  from  the  occlusal  surface  of  the  tooth;  or 
erosion  proceeding  from  the  labial  or  buccal  surface.  Hence, 
we  are  forced  to  the  conclusion  expressed,  that  all  of  this 
change  has  occurred  through  reflex  action,  and  is  not  localized 
in  any  part  of  the  pulp  chamber,  but  is  general  to  the  pulp  cham- 
bers and  to  the  teeth  of  the  individual.  (See  Figures  325  and 
326.) 

None  of  those  who  have  reported  investigations  along  this 
line  seem  to  have  made  what  I  would  consider  extended  examina- 
tions, involving  a  sufficient  number  of  teeth,  under  the  varied 
conditions  under  which  calcification  begins  and  its  progress  con- 
tinues; consequently  they  have  not  had  variety  enough  to  give 
just  conceptions  of  the  beginning  and  progress. 

I  began  my  studies  with  the  ideas  derived  from  this  litera- 
ture, with  the  expectation  of  finding  them  correct.  In  some  cases 
this  seemed  to  be  confirmed  in  observations  of  differences  in  the 
thickness  of  the  growth  in  different  parts  of  the  pulp  chamber, 
'^riiese  differences  were,  however,  discovered  to  be  in  the  walls 
of  the  pulp  chamber  remote  from  the  point  of  irritation,  as  well 
as  upon  parts  over  the  fibrils  irritated.  Therefore,  I  feel  that 
the  descriptions  in  the  literature,  of  this  strict  localization  of 
deposits  to  the  portions  of  the  fibrils  injured,  has  been  too  hastily 
assumed.  Instead  of  examining  as  many  as  forty  teeth,  as 
expressed  by  Salter,  it  requires  examinations  of  hundreds  of 
teeth  for  reliable  determination  of  this  question. 

I  have  thought  that  T  could  determine  this  matter  more 
definitelv  if  I  could  obtain  teeth  of  children  that  had  been  so 


CALCIFICATIONS    OF    THE    DENTAL   PULP.  271 

broken  at  an  early  period,  as  to  expose  a  large  area  of  the 
dentinal  fibrils,  but  in  which  the  pulp  had  remained  alive.  Such 
a  case  would  present  an  isolated  exposure  of  the  dentinal  fibrils. 
I  have  thought  to  examine  these,  to  determine  whether  or  not  a 
building  of  secondary  dentin  had  occurred  over  the  pulpal  ends 
of  those  fibrils  which  were  exposed  to  irritation.  Opportunities 
for  such  examinations  have,  however,  eluded  me  to  such  an 
extent  that  I  have  been  unable  to  determine  the  point  satis- 
factorily. 

The  effect  upon  the  dentin  and  enamel.  The  effect  upon 
the  dentin  of  cutting  off  the  fibrils  from  the  pulp  is  to  destroy 
its  life.  The  secondary  dentin  may  grow  and  narrow  the  pulp 
chamber  without  affecting  the  dentinal  fibrils,  but  when  the 
dentinal  fibrils  have  dropped  out,  and  a  clear  calcification  begins, 
the  fibrils  in  the  dentin  die.  Those  tubules  which  are  exposed  to 
the  saliva  become  filled  and  soddened  with  the  materials  of 
decomposition  which  occur  in  the  mouth,  and  in  time  the  whole 
of  this  area  of  dentin  becomes  softer  than  normal.  It  can  be 
cut  without  pain  to  the  patient,  though  the  line  of  demarcation 
as  to  pain  is  in  many  of  the  cases  much  broader  than  the  expo- 
sure of  the  ends  of  the  tubules  would  indicate. 

The  softening  of  the  dentin  renders  the  enamel  much  more 
liable  to  break  away  from  it  than  from  healthy  dentin.  This  is 
a  matter  to  be  reckoned  with  in  all  of  our  operative  procedures. 
This  subject  is  considered  in  my  work  on  Operative  Dentistry. 
I  will  only  mention  here  the  natural  consequences  of  the  failure 
of  the  dentinal  fibrils  to  pass  regularly  from  the  pulp  through 
the  dentin,  and  keep  up  the  life  which  should  exist  in  that  tissue. 

Abraded  dentin  becomes  darker,  fibrils  die.  The  abraded 
dentin  becomes  darker  than  normal,  causing  the  clear  calcifica- 
tion to  stand  out  more  prominently  in  cases  in  which  the  wear 
has  involved  the  positions  of  the  former  pulp  chamber.  When 
sections  are  cut  centrally  toward  the  pulp  through  the  exjiosod 
fibrils,  an  area  of  darkened  dentin  will  be  discovered,  which 
includes  the  fibrils  of  this  exposed  area  from  the  enamel  to  the 
pulp.  Examinations  of  teeth  in  the  mouth  will  show  that  this 
area  of  dentin  has  lost  its  sensitiveness,  or  in  other  words,  that 
the  fibrils  are  dead.  If  one  cuts  beyond  this  line,  the  dentin  will 
be  found  to  be  normally  sensitive.  In  examinations  of  worn 
areas,  as  they  may  be  discovered  in  the  mouth,  the  color  of  the 
worn  dentin  will  indicate  whether  or  not  the  fibrils  are  alive. 
If  the  worn  dentin  is  bright,  or  of  normal  color,  the  area  will 
usually  be  sensitive  and  the  fi1)rils  will  still  be  living.     If  the 


272  SPECIAL   DENTAL.   PATHOLOGY. 

worn  dentin  in  the  area  is  found  to  have  become  yellow,  or 
darkened,  it  will  not  be  sensitive  because  the  fibrils  will  have 
died. 

Exposure  of  pulp  by  abrasion  and  erosion.  These  calcifica- 
tions act  as  a  protection  against  the  exposure  of  the  pulp  by 
abrasion  or  by  erosion.  It  is  a  rare  thing,  which  I  have  seen 
but  a  time  or  two  in  my  life,  that  erosions  have  progressed 
rapidly  enough  to  have  exposed  the  pulp.  They  may  go  on  and 
cut  a  tooth  in  two,  allowing  its  crown  to  drop  away,  but  before 
they  have  reached  the  pulp,  the  pulp  will  have  been  protected 
l)y  a  growth  of  secondary  dentin,  and  the  cutting  i)roceeds 
through  this  secondary'  growth  in  removing  the  crown  of  the 
tooth.    (See  Figure  317.) 

I  have  seen  the  pulp  exposed  very  much  oftener  in  what  we 
may  term  the  ordinary  abrasion  of  the  teeth,  than  from  erosion. 
Generally  this  exposure  in  abrasion  will  be  of  the  tips  of  the 
horns  of  the  pulp,  arousing  first  the  symptoms  of  hyperemia, 
soon  followed  by  an  inflammation.  This  generally  occurs  in 
cases  in  which  the  horns  of  the  pulp  are  unusually  long,  and  the 
abrasion  beginning  upon  the  cusps  exposes  them.  In  those 
cases  one  may  not  be  able  to  see  an  exposure  of  the  pulp,  but  by 
taking  a  very  fine  broach  and  placing  the  point  successively 
about  the  central  part  of  the  abrasion,  where  tlie  horn  of  the 
pulp  should  be,  the  point  is  likely  to  drop  into  a  very  fine  open- 
ing, which  reveals  the  exposure. 

Effect  upon  the  pulp.  While  I  have  found  very  little  in 
the  symptomatolog;^^  to  indicate  it,  as  a  general  rule  I  think  it 
will  be  found  that  the  injurious  effect  upon  the  pulp  has  been 
slower  in  cases  in  which  the  fibrils  have  crossed  the  line  and 
entered  some  distance  into  the  new  formation. 

I  have  cut  sections  of  many  teeth  with  the  especial  view  of 
studying  this  point,  in  cases  in  which  I  have  taken  the  symptom- 
atology^ myself,  or  have  had  very  exact  expressions  of  it  from 
those  who  had  examined  the  cases.  In  so  doing  I  found  that  the 
symptomatology^  did  not  aid  me  in  determining  what  calcificji- 
tions  would  be  found.  When  calcifications  have  made  consider- 
able extensions  upon  the  walls  of  the  pulp  chamber,  narrowing 
it,  there  is  a  marked  effect  produced  upon  the  pulp  tissue.  The 
cells  of  the  pulp  dwindle  in  size,  and  as  the  deposit  becomes  clear 
the  odontoblasts  disappear,  and  the  pulp  tissue  simply  lies 
against  the  growing  clear  calcification  without  the  interposition 
of  the  odontoblastic  layer.  (See  Figures  330  and  331.)  The 
effect  upon  the  pulp  is  more  pronounced  than  in  the  cases  in 


CALCinr'ATTONS    OF    THE    DENTAL   PULP.  273 

which  the  calcification  is  tubular.  Indeed,  in  the  one  case  it  is 
not  properly  secondary  dentin  at  all,  but  a  clear  deposit;  in  the 
other  it  is  true  secondary  dentin  for  a  space,  which  gradually 
gives  way  to  clear  calcification  by  the  thinning  out  of  the  den- 
tinal tubules,  with  a  corresponding  droi)ping  out  of  the  odonto- 
blastic layer.  The  effect  upon  the  dental  pulp  deepens  as  the 
accumulation  in  the  pulp  chamber  becomes  greater.  Many  of 
the  cellular  elements  disappear,  or  become  mere  threads,  and 
the  general  expression  given  by  the  field  under  the  microscope 
is  that  the  tissue  has  become  more  distinctly  fibrous  until  its 
structure  is  greatly  changed.  As  this  goes  on,  the  pulp  usually 
becomes  insensitive  and  fails  entirely  to  respond  to  temperature 
changes.  The  condition  is  a  more  or  less  complete  loss  of  func- 
tion by  the  pulp.  (See  Figures  327,  328  and  329.)  Finally  death 
of  the  remaining  portions  of  the  pulp  occurs. 

This  is  true  of  all  kinds  of  calcifications  which  materially 
fill  up  the  pulp  chamber.  A  few  calcifications  scattered  through 
the  mass  of  the  pulp  tissue  do  not  seem  to  produce  this  effect. 
In  this  consideration  it  seems  that  the  only  difference  in  effect 
between  the  calcifications  beginning  as  clear  calcifications,  and 
those  that  begin  as  secondary  dentin  proper,  is  found  in  the  sud- 
denness of  the  inter])osition  of  clear  calcifications  to  prevent 
the  communication  of  the  living  pulp  with  the  fibrils  of  the  den- 
tin. 

Thus  in  the  beginning,  the  effect  produced  by  these  calcifica- 
tions is  to  ]irotect  the  pul])  for  the  time  from  exposure  by  exten- 
sive wear,  or  other  injui'ious  processes  going  on,  which  keep  the 
fibrils  in  a  state  of  irritation.  This  effect  is  beneficent,  as  it 
gives  a  nearly  normal  usefulness  of  the  teeth  for  a  much  longer 
time  than  could  otherwise  occur.  Tt  also  greatly  lessens  the 
chance  of  early  iufiaiuination  and  death  of  the  pulp. 

On  the  other  hand,  the  amount  of  pulp  tissue  left  in  the 
root  portion  of  the  pulp  chamber  has  become  very  small  in  most 
of  these  cases.  The  apical  foramen  is  also  reduced  to  the  nar- 
rowest limits,  yet  I  have  never  seen  a  case  in  which  it  was 
entirely  closed. 

These  cases  occur  mostly  in  what  we  may  term  old  age ;  or 
we  have  the  conditions  of  old  age  to  deal  with  in  the  teeth, 
although  the  person  may  not  yet  be  old.  There  is  tiie  same  nar- 
rowing of  the  pulj)  chamber,  and  the  same  narrowing  of  the 
apical  foramen  in  the  latter  stages  of  these  cases,  which  occur 
in  the  teeth  of  a  very  old  person  when  normal  conditions  have 
existed  until  late  in  life.    Tn  other  words,  it  is  a  premature  clos- 

26 


274  SPECIAL   DENTAL   PATHOLOGY. 

ing  out  of  the  life  of  the  pulp  of  the  tooth.  Any  considerable 
extension  of  the  calcification  on  the  inner  wall  of  the  pulp  cham- 
ber, or  indeed  within  the  pulp  tissue,  means  the  final  death  of 
the  pulp.    In  most  cases,  this  process  extends  over  many  years. 

Dangek  of  ALVEOLAR  ABSCESS.  lu  tlicso  cases  the  conditions 
for  the  production  of  alveolar  abscess  would  seem  to  be  reduced 
to  the  minimmn  by  the  small  amount  of  tissue  composing  the 
dead  pulp,  and  the  extreme  narrowing  of  the  apical  foramen. 
There  is  a  further  consideration,  that  in  the  majority  of  these 
cases  there  is  no  infection  introduced  through  an  exposure  of 
the  pulp.  This  gives  a  fair  assurance  of  continued  health  to  the 
parts.  It  rarely  occurs  that  such  a  pulp  becomes  infected 
through  the  blood  stream  by  way  of  the  apical  foramen.  As  a 
matter  of  fact  the  formation  of  alveolar  abscess  is  not  common 
about  the  roots  of  these  teeth. 

In  studying  these  cases  with  the  microscope,  we  occasionally 
find  a  filament  of  the  living  pulp  running  far  along  to  one  side 
of  the  main  body  of  the  calcification.  If  the  wear  should  open 
into  this,  as  it  sometimes  does,  we  may  be  surprised  by  the  sud- 
den occurrence  of  an  acute  alveolar  abscess.  A  number  of  such 
cases  have  occurred  in  my  practice,  and  I  made  cross  sections  of 
the  teeth,  the  pulp  tissues  of  which  were  deeply  calcified,  and  in 
several  of  these  I  found  a  fine  opening  running  along  the  side 
of  the  calcification  near  one  of  the  walls  of  the  original  pulp 
cavity  wliich  explained  the  occurrence  of  the  abscesses. 

Calcifications  Growing  Free  in  the  Tissues  of  the  Pulp, 
Unattached  to  the  Walls  of  the  Pulp  Chamber. 

Variety  of  forms.  These  calcifications  take  a  multitude  of 
forms.  The  most  common  are  the  nodular  formations  in  the 
bulb  of  the  pulp,  ordinarily  spoken  of  as  pulp  nodules  or  pulp 
stones.  (See  Figures  332,  333  and  334.)  Next  in  frequency  are 
the  fusiform,  or  spindle-shaped,  calcifications  in  the  root  por- 
tions of  the  pulp.  In  some  cases  the  various  calcifications  in 
the  root  portions  are  joined  together.  (See  Figures  335,  336 
and  337.)  Occasionally,  all,  or  nearly  all,  of  the  tissue  within 
the  pulp  chamber  and  root  canals  is  found  calcified,  either  in  a 
single  mass,  or  in  several  masses,  more  or  less  closely  united. 

On  making  sections  for  microscopical  study,  most  of  these 
calcifications  are  found  to  be  homogeneous  or  clear  calcifications. 
These  are  all  nontubular.  These  sometimes  have  threads  of 
tissue  which  are  not  calcified,  irregularly  mingled  in  their  sub- 
stance.    In  some  specimens  there  are  many  of  these,  in  some 


CALCIFICATIONS   OF    THE    DENTAL   PULP.  275 

very  few,  and  in  others  none.  What  the  physiological  process 
of  the  growth  may  be  in  these  clear  calcifications  seems  not  to 
have  been  made  out.  I  have  not  found  the  onion-lilve  layers 
which  belong  to  calco-spherites.  These  are  certainly  not 
deposited  after  the  fashion  of  the  deposits  of  calcium  salts  in 
the  building  of  the  dentin,  enamel  or  calco-spherites ;  otherwise 
we  would  find  these  layers  a  prominent  factor,  which  we  do  not. 
Occasionally  calco-spherites  occur.  These  are  the  only  definite 
forms  found  in  the  calcifications  unattached  to  the  walls  of  the 
pulp  chamber.  They  will  be  considered  more  in  detail  in  the 
following  pages.  In  the  bulbs  of  the  pulps  of  molar  teeth  the 
calcifications  may  be  round  or  irregular  in  their  formation.  If 
they  are  very  irregular  and  nodular,  they  are  apt  to  include  a 
few  calco-spherites  and  sometimes  many  of  them. 

Another  very  curious  form  is  that  in  which  the  root  por- 
tion is  filled  more  or  less  completely  with  long  spiculse  of  hard 
formations  which  seem  to  be  jointed,  the  ends  resting  loosely 
upon  each  other.  These  give  a  stiifened  appearance  to  a  pulp 
that  is  removed  when  in  this  condition,  which  has  been  called 
the  lead-wire  formation.  Such  a  pulp  seems  stiff.  You  may 
bend  it  in  any  way  and  it  will  stay  just  as  you  have  bent  it,  as 
would  a  piece  of  soft  lead  wire. 

Sometimes  we  see  pulp  stones  of  conglomerate  character 
that  have  filled  up  the  entire  bulbal  portion  of  the  pulp  of  a 
molar  tooth  without  having  any  attachment  whatever  to  the 
walls  of  that  cavity.  When  we  come  upon  them  in  the  effort  to 
remove  the  pulp,  we  find  that  they  have  a  slight  movement  in 
the  pulp  chamber,  showing  that  they  are  not  attached  to  the 
walls.  These  curious  forms  may  contain  many  calco-spherites ; 
they  may  contain  a  few,  or  they  may  contain  none.  When  a  sec- 
tion is  made  we  may  find  a  clear  calcification  showing  no  forms, 
or  it  may  have  fibers  running  irregularly  through  it. 

It  is  my  opinion  that  these  calcifications  in  the  bulb  of  the 
pulp  are  less  frequent  than  the  calcifications  in  the  root  portion. 
Those  m  the  root  portion  are  fusiform  calcifications  in  the  main, 
with  their  length  disposed  parallel  with  the  length  of  the  root 
canal.  They  generally  seem  to  have  fibers  of  tissue  attached 
to  them,  and  especially  to  their  ends,  and  sometimes  they  are 
considerably  marked  by  fibers  running  through  them,  the  forms 
of  which  seem  not  to  be  under  any  special  control.  There  is 
nothing  in  them  that  we  can  consider  as  dentin,  or  the  attempt 
to  form  dentin.  They  simply  grow  there,  finally  in  such  num- 
bers as  to  strangle  the  tissues  of  the  pulp  and  cause  its  destruc- 


276  SPECIAL    DENTAL    PATHOLOGY. 

tion.  This  seems  not  dependent  upon  tlie  same  causes  .that 
bring  about  secondary  dentin. 

I  have  found  nodules  in  the  bulbs  of  pulps  of  teeth  from 
children  fifteen  or  sixteen  years  old.  These,  however,  are  some- 
what rare.  They  are  found  oftener  in  the  pulps  of  teeth  of 
persons  in  or  past  middle  life. 

Generally  no  symptoms.  There  are  some  writings  which 
represent  the  efforts  of  persons  to  diagnose  the  presence  of 
these  clear  calcifications.  Many  have  had  the  idea  that  the 
growth  of  these  bodies  was  productive  of  some  of  the  obscure 
pain  found  in  regions  about  the  mouth.  In  comparing  my  his- 
tories and  my  cuttings  in  cases  where  I  have  found  these,  I  have 
been  unable  to  trace  them  to  any  connection  with  such  pain. 
True,  I  have  sometimes  found  them  in  cases  in  which  there  was 
complaint  of  pain,  but  I  have  found  them  oftener  in  cases  in 
which  there  had  been  none.  Taking  my  studies  as  a  whole,  they 
indicate  that  the  growth  of  these  calcifications  produces  no  par- 
ticular symptoms. 

The  same  is  true  of  the  growth  of  calcifications  generally 
in  the  pulp  tissue,  or  attached  to  the  walls  of  the  pulp  chamber. 
They  are  all  painless  processes  and  give  rise  to  no  symptoma- 
tology, so  far  as  I  have  been  able  to  discover.  They  present 
difficulties  in  the  removal  of  pulps,  and  in  penetrating  root 
canals,  especialh'  when  the  mass  in  the  root  canal  portion  has 
become  very  great  so  as  to  materially  fill  the  canal. 

Tendency  to  destroy  pulp.  Attention  has  l)een  called  to 
the  fact  that,  while  the  deposit  of  true  secondary  dentin  is  for 
the  time  beneficent,  yet  when  started,  the  growth  continues  to 
the  destruction  of  the  pulp  of  the  tooth.  This  tendency  to 
destroy  the  pulp  is  found  also  in  the  calcifications  within  the 
pulp  tissue,  especially  those  in  the  root  portion.  I  think  that  a 
considerable  number  of  these  calcifications  may  continue  in  the 
root  of  the  tooth  for  many  years  without  doing  a])parent  injury, 
provided  their  crowding  out  of  that  tissue  is  not  too  great. 

The  Treatment  for  Limitation  of  Calcifications  within  the 

Pulp  Chamber. 
The  principal  reason  for  presenting  the  subject  of  calcifica- 
tions in  the  pulp  chamber  is  to  impress  the  importance  of  recog- 
nizing the  relationship  of  abrasion  and  erosion  to  these  forma- 
tions, and  of  applying  y)roper  treatment  sufficiently  early  to  be 
effective  in  limiting  their  progress.  This  treatment  must  be 
prophylactic  in  its  character.     One  must  have  in  mind  a  clear 


Fig.  332. 


Fig.  333. 


jii^^:^^^^^^^p^^~^^^~~^-'<-  '____j*i- -' 


^^'  «n^  w^-'urz^/y^x^.y  ///rr,.j 


;r<;^^<**^ 


Fig.  332.  A  small  i)ulp  iiodulo  ns  soon  witli  :i  low  powor.  slitiwiii-,'  its  nochilat  ion  : 
a  roprosonts  the  act\ial  si/.r. 

Fig.  333.  Soctinn  nf  ,-i  pulp  ikhIiiIc  sliowin:;  iii;iiiy  en  leu  splicrit  I's.  ;is  pdintotl 
out  by  a,  a. 

Fig.  3.'U.      i'nlp  iiiiiliili-s  III   till'  cniinl   |inr1iiiii  uf  llic   )iiilp. 


<«26 


Fig.  335. 


Fig.  336. 


Fig   337. 


Fig.  335.  Outline  of  a  lower  molar  with  a  large  carious  cavity  at  a.  b,  Pulp 
chamber.  The  shaded  portion,  c,  was  occupied  by  cylindrical  calcifications.  Sketch 
of  the  cylindrical  calcification  shown  to  the  right. 

Fig.  336.  Cylindrical  calcification  of  the  pulp.  This  has  been  spread  with 
needles,  and  the  fibers  that  lay  across  the  general  trend  show  how  the  calcifications 
are  attached  at  the  end  to  the  fibers.  It  will  also  be  noticed  that  the  tissue  has  lost 
its  normal  forms  and  degenerated  into  an  irregular  fibrous  mass. 

Fig.  337.  Cylindrical  calcification,  more  advanced  than  in  Figures  335  and  336. 
Instead  of  running  together  and  forming  a  solid  mass,  these  are  irregularly  jointed. 


CALCIFICATIONS    OF    THE    DENTAL   PULP.  277 

conception  of  the  conditions  which  induce  calcification,  and 
apply  treatment  for  the  removal  or  amelioration  of  those  con- 
ditions. Treatment  may  be  applied  most  successfully  to  abra- 
sions and  erosions  of  the  teeth,  also  to  a  more  limited  extent  to 
the  calcifications  which  occur  because  of  the  exposure  of  the 
fibrils  in  caries  of  the  teeth. 

Treatment  of  abrasion. 

In  determining  the  plan  of  treatment  to  be  followed  inquiry 
should  first  be  made  as  to  whether  or  not  other  members  of  the 
family  have  had  extensive  abrasions  of  the  teeth.  The  number 
of  areas  presenting  and  the  extent  of  the  wear  should  be  care- 
fully noted.  This  information  will  indicate  the  probability  of 
success  in  the  treatment.  It  is  my  judgment,  from  observa- 
tion of  many  cases,  that  treatment  may  be  employed  with  good 
effect  in  cases  in  which  the  areas  presenting  are  small,  and  par- 
ticularly if  the  patient  complains  of  pain  in  biting  upon  the 
abraded  areas.  It  is  of  importance  to  apply  treatment  very 
early  in  cases  in  which  there  may  be  evidence  of  hereditaiy 
predisposition. 

In  the  treatment  of  the  more  recent  abrasions,  in  which  one 
or  several  teeth  present  with  slight  cupping  of  the  dentin,  cavi- 
ties should  be  cut  which  will  include  each  area,  making  such 
undercuts  in  the  dentin  beyond  that  which  is  exposed  on  the  sur- 
face as  will  give  good  retention  form.  In  the  preparation  of 
such  a  cavity,  the  dentin  should  be  cut  no  deeper  at  any  point 
than  is  necessarj^  for  the  retention  of  the  filling.  The  cavity 
should  be  filled  with  gold  foil,  or  in  preference,  platinum-gold 
foil  for  the  greater  ]iortion  of  the  filling.  I  have  found  platinum- 
gold  to  wear  a  little  better  than  pure  gold,  hence  the  recom- 
mendation of  its  use  for  these  fillings.  Another  point  of  minor 
importance  is  that  the  color  of  platinum-gold  is  less  objection- 
able, particularly  in  those  cases  in  which  several  fillings  must 
be  made  in  the  front  teeth. 

This  filling  should,  in  all  cases,  be  made  as  hard  as  it  is 
possible  to  make  it  by  heavy  malleting.  In  practically  all  such 
cases,  the  heavy  use  of  the  teeth  in  mastication  has  rendered  the 
membranes  firm  and  unyielding,  so  tliat  heavy  mallet  pressure 
may  be  applied  without  discomfort  to  the  patient.  The  cup  that 
has  been  formed  should  be  filled  full  and  built  out  sufiiciently  to 
receive  the  occlusion  of  the  opposing  tooth  upon  its  surface,  and 
then  trimmed  just  enough  to  render  the  occlusion  reasonably 
comfortable.     The  intention  should  be  to  catch  the  occlusion 

26b 


278  SPECIAL   DENTAL    PATHOLOGY. 

upon  the  fillings.  If  tliere  are  other  areas  in  which  the  dentin 
lias  been  exposed,  they  sliould  receive  similar  treatment.  The 
case  should  be  followed  by  watchfulness  and,  as  the  dentin 
becomes  exposed  by  the  wearing  away  of  the  enamel  at  other 
points,  fillings  should  be  made. 

As  time  passes,  these  fillings  will  become  worn.  The  harder 
they  are  made  in  the  beginning,  the  slower  this  wear  will  be,  but 
in  the  general  wear  of  the  teeth,  independent  of  this  cupping 
process,  the  shallow  fillings  which  are  first  made  will  wear  out 
and  other  fillings  must  be  substituted  as  rapidly  as  this  occurs. 
The  rule  must  be  that  the  least  possible  abrasion  of  the  dentin 
will  be  permitted. 

In  my  practice  this  plan  of  treatment  has  been  the  most 
satisfactory.  A  number  of  cases  have  been  followed  long  enough 
to  establish  this  fact.  This  is  true  regardless  of  the  question 
of  heredity. 

It  must  be  understood  that  the  patient  is,  in  the  beginning, 
to  be  impressed  with  the  fact  that  no  point  of  wear  should  be 
allowed  to  proceed  after  sensitiveness  has  occurred,  but  should 
be  at  once  protected  by  a  filling,  and  that  this  is  to  be  followed 
year  after  year,  as  other  points  of  wear  occur. 

This  treatment  will  serve  to  protect  the  exposed  fibrils  and 
give  them  rest  from  irritation  and,  at  the  same  time,  avoid 
injuiy  of  the  pulp  tissue  from  calcifications.  It  will  also  effec- 
tively limit  the  abrasion  of  the  teeth.  This  means  a  more  or 
less  complete  prophylactic  treatment  against  the  occurrence  of 
the  evils  resulting  from  calcifications. 

Building  up  op  extensive  abrasions  of  the  teeth.  There 
are  in  the  literature  a  number  of  papers  dealing  with  the  build- 
ing up  of  badly  abraded  teeth  by  opening  the  bite  suificiently  to 
restore  approximately  their  normal  length.  I  have  studied  this 
plan  of  treatment  and  its  results  in  the  practice  of  dentists,  who 
have  frequently  employed  it,  and  by  the  observation  of  cases 
that  have  been  treated  in  this  way,  as  well  as  by  the  teaching 
of  my  own  attempts  in  this  direction.  I^'^ndoubtedly,  this  plan 
may  be  followed  to  great  advantage  when  wear  has  affected  a 
limited  number  of  teeth,  while  the  remainder  occlude  in  such  a 
way  as  to  prevent  wear.  It  should  be  understood  that  wear  of 
the  teeth  occurs  most  in  those  cases  where  considerable  lateral 
•motion  may  be  given  to  the  teeth  in  chewing  food,  and  least 
where  the  intercusping  of  the  teeth  prevents  such  lateral  motion. 
In  some  mouths  the  lateral  movement  will  be  such  that  there  is 
a  considerable  sliding  motion  of  certain  teeth  in  bringing  the 


CALCIFICATIONS   OF    THE    DENTAL   PULP.  279 

teeth  to  the  full  intereusping  in  complete  occlusion.  These  teeth 
may  be  worn,  while  others  are  not.  If  taken  in  time,  the  build- 
ing up  of  the  worn  teeth  may  be  of  advantage,  even  though  quite 
a  little  wear  has  occurred.  For  instance,  it  occasionally  happens 
that  the  incisor  teeth  become  badly  worn  and  are  becoming  short, 
while  the  bicuspids  and  molars  have  not  been  much  worn.  In 
these  cases  such  building  as  will  limit  the  wear  becomes  impor- 
tant and  the  wear  of  these  teeth  may  be  delayed  by  the  careful 
substitution  of  gold  in  such  bulk  as  will  not  limit  the  occlusion. 
It  may  be  possible  to  hold  a  sufficient  proportion  of  such  teeth 
for  many  years,  if  not  permanently.  Other  cases  simulating  the 
above,  where  some  teeth  wear  and  others  do  not,  are  often  sus- 
ceptible to  this  treatment.  By  making  careful  selections  of 
cases,  much  may  be  done  in  protecting  teeth  and  also  in  protect- 
ing the  pulps  from  calcifications. 

My  experience  and  that  of  others  gives  a  sharp  warning 
against  undertaking  the  building  up  of  extensive  abrasions  of 
the  teeth.  Wlien  great  numbers  of  teeth  have  been  built  up, 
opening  the  bite,  some  of  the  operations  usually  fail  within  a 
few  years,  from  one  cause  or  another.  Most  of  these  failures 
occur  from  breakage  of  the  teeth,  so  that  the  fillings  become 
loose.  As  time  passes,  more  and  more  of  this  breakage  occurs. 
This  is  due  doubtless  in  the  main  to  a  want  of  appreciation  of 
the  fact  that  the  dentin  is  softened  and  that  the  whole  of  the 
enamel  supported  by  the  softened  dentin  is  much  more  brittle 
than  normal.  The  filling,  therefore,  has  not  an  anchorage  that 
is  sufficient  to  sustain  it  against  the  heavy  stress  brought  upon 
it.  In  studying  these  breakages,  I  have  found  that  the  anchor- 
age in  most  of  them  was  as  secure  as  it  could  be  made,  and  have 
come  to  regard  the  failures  as  unavoidable  because  of  the  exis- 
ting conditions. 

Danger  of  approaching  too  close  to  pulp  in  preparing 
CAVITIES.  Another  condition  has  arisen  in  a  number  of  cases 
that  have  come  under  my  observation,  which  seems  difficult  to 
avoid.  In  seeking  the  best  possible  anchorage  for  fillings  in 
such  worn  teeth,  one  is  very  likely  to  approach  the  pulp  too 
closely,  inducing  the  premature  death  of  the  pulp.  Such  a  result 
is  particularly  distressing. 

Treatment  of  erosion. 

I  have  thought  that  something  might  l)o  done  with  a  view  to 
limit  the  injury  to  the  pulp  tissues,  by  tlie  calcifications  whicli 
occur  upon  the  walls  of  the  pulp  chamber  in  erosion.     I  have 


280  SPECIAL    DENTAL    PATHOLOGY. 

tried  this  in  a  number  of  cases,  but  not  sufficiently  to  have 
formed  a  good  judgment  as  to  its  value.  Such  treatment  was 
applied  to  cases  in  which  the  cutting  was  of  definite  wedge  form 
in  the  gingival  third  of  the  labial  surfaces  of  the  incisors  and 
cuspids. 

If  a  cavity  is  prepared  and  a  filling  placed  when  the  erosion 
has  proceeded  so  far  as  to  cut  through  the  enamel,  exposing  the 
dentin,  the  depth  of  the  erosion  will  be  limited  and  further  irrita- 
tion of  the  dentinal  fibrils  will  be  prevented.  Generally,  how- 
ever, this  will  not  limit  the  breadth  of  the  erosion  upon  the 
surface  of  the  tooth  and,  unless  the  cavity  is  cut  wide  in  the 
beginning,  the  erosion  will  soon  begin  along  the  margins  of  the 
filling.  This  will  call  for  a  new  filling,  wider  than  the  first.  Tu 
many  of  the  erosions  this  plan  might  be  followed  until  the  widen- 
ing of  the  erosion  ceases ;  that  is,  until  the  erosion  has  reached 
what  would  be  its  full  breadth. 

This  plan  of  treatment  is  encouraged  by  the  fact  that  the 
erosion  is  liable  to  stop  at  any  point  in  its  progress  and  not 
again  become  active.  If  so,  we  will  have  made  effective  pro- 
phylaxis of  the  injury  to  the  pulp  by  this  treatment.  This  plan 
may  be  applied  to  the  wedge  form  of  erosion  with  better  proba- 
bility of  success  than  to  any  other,  as  the  wedge  forms  are 
inclined  to  cut  deeply,  without  much  spreading  on  the  surface. 
It  should  not  be  attempted  in  any  case  in  which  the  erosion  is 
inclined  to  make  a  very  broad  shallow  cut. 

The  Formation  of  Calco-spherites. 

The  term  calco-spherites  is  applied  to  calcium  deposits 
arranged  in  concentric  spheres.  The  formations  of  calco- 
spherites  are,  I  think,  less  common  than  the  reading  of  our 
literature  would  indicate.  They  are  found  only  occasionally 
among  the  calcifications  which  occur  in  the  pulp  tissue,  but  are 
often  prominent  objects  when  they  are  found.  These  are  very 
peculiar  and  characteristic  growths,  having  markings  similar 
to  those  of  a  tiny  onion  cut  across  equatorially  —  that  is,  con- 
sidering the  top  of  the  onion  one  pole  and  the  root  the  other 
pole,  and  cutting  it  across  the  center  between  the  two,  which 
shows  the  markings  most  regularly  around  it.  The  calco- 
spherite  resembles  this  more  in  appearance  than  any  other 
object  I  know  in  nature. 

We  know  very  little  positively  of  the  manner  of  the  forma- 
tion of  the  calco-spherites.  The  curious  experiments  of  Eainey 
and  Ord,  which  have  been  repeated  by  others,  including  myself, 


Fig.  338. 


Fig.  339. 


Figs.  338,  339.  Artificially  formed  calco-aphpritos  from  book  ontitled :  "  On  the 
Mode  of  Formation  of  .Shells  of  Animals,  of  Bone  an<l  of  Several  other  Structures, 
by  a  Process  of  Molecular  Coalescence,"  by  George  Kainey,  M.  R.  C.  S.,  1858. 
Fig.  338  "  represents  calculi  as  they  are  found  on  the  under  surface  of  the  slides." 
Fig.  339  "represents  one  form  of  <,Hohiile  soiiiclimes  found  ))oth  in  the  deposit  and 
on  the  slides,  as  well  as  the  most  pci  ret  runns  ul'  thr  liiiiiinated  calculi  with  radii." 
(See  reference  in  text.) 


;v\ri*-V  ;;.^-JCJ\•i.'g>.;. 


Fir,,  r^-11. 


Fig.  340.  Deposit  of  unusual  form  within  the  tissues  of  an  inflamed  pulp  of  a 
tooth  of  a  child  of  14.     This  deposit  was  soft  enough  to  be  readily  cut  with  a  knife. 

Fig.  341.  Calco-spherite-like  spherule  in  the  tissues  of  the  peridental  membrane: 
a,  Spherule,  b,  Cementum,  showing  the  fibers  of  the  peridental  membrane  springing 
from  it.  c,  Principal  fibers  of  membrane,  d,  Indifferent  tissue.  For  a  small  space 
no  fibers  are  attached  to  the  cementum. 


CALCIFICATIONS    OF    THE    DENTAL    PULP.  281 

have  drawn  general  attention  to  the  calco-spherites,  and  to  their 
composition.  Calco-spherites  may  be  produced  artificially  by 
taking  a  solution  of  albumen,  or  an  albuminoid  substance  in 
water,  to  which  is  added  a  small  amount  of  finely  pulverized 
calcium  salts.  The  solution  should  then  be  impregnated  with 
carbon  dioxid  under  pressure.  This  should  be  sealed  and  set 
aside  in  a  still  place  for  several  months,  at  the  end  of  which 
time  it  will  be  foimd  that  calco-spherites  have  formed  and  fallen 
to  the  bottom. 

In  the  body  we  are  most  likely  to  find  calco-spherites  in 
positions  in  which  there  has  been  stagnation  of  the  blood,  as  in 
cases  of  phleboliths  found  in  varicose  veins. 

The    ARTIFICIAL    FORMATION    OF    CALCO-SPHERITES. 

A  book  by  Rainey  was  published  by  John  Churchill  in  Lon- 
don, in  1858,  in  which  he  described  minutely  a  method  for  the 
artificial  formation  of  calco-spherites  and  gave  numerous  draw- 
ings to  illustrate  the  various  steps  in  the  formation  of  these 
calculi.  This  book  was  published  during  the  same  year  as 
Virchow's  work  on  cellular  pathology,  which  finally  convinced 
the  world  of  the  correctness  of  the  cell  theory.  Kainey  unfor- 
tunately denied  all  possibility  of  cellular  elements  in  life  force, 
whicli  at  the  present  time  naturally  detracts  from  proper  con- 
sideration of  other  questions  discussed  by  him. 

Rainey 's  book  contains  152  pages,  closely  printed.  The 
sentences  are  very  long.  In  many  respects  the  book  is  a  curios- 
ity. It  is  occupied  with  a  detailed  account  of  the  author's  con- 
ception that  the  shells  of  the  mollusea,  in  their  formation,  are 
practically  identical  with  the  formation  of  the  calco-spherites, 
which  is  described.  He  ascribes  the  same  principle  discovered 
in  the  formation  of  the  calculi  to  the  formation  of  bone  in  the 
lower  animals  and  in  man.  I  have  had  two  of  the  illustrations 
in  this  book  reproduced  for  this  publication.  (See  Figures  838 
and  339.)     In  his  description  he  gives  the  following  as  a  plan: 

"This  process  is  given  in  the  Transactions  of  the  Micro- 
scopical Society,  published  in  the  Quarterl}^  Journal  of  Micro- 
scopical Science  for  January,  1858.  It  consists  of  introducing 
into  a  two-ounce  phial,  about  three  inches  in  height,  with  a  mouth 
al)out  one  inch  and  a  quarter  in  width,  half  an  ounce  by  measure 
of  a  solution  of  gum  aral)ic  saturated  with  carbonate  of  i)otasli 
(the  subcarbonate  of  the  old  pharmacopoeias).  The  specific 
gravity  of  the  compound  solution  should  l)e  1.40ns,  when  one 
ounce  will  weigh  672  grains.     This  solution  must  be  perfectly 


282  SPECIAL    DENTAL   PATHOLOGY. 

clear;  all  of  the  carbonate  of  lime  which  had  been  formed  by  the 
decomposition  of  the  malate  of  lime  contained  in  the  gmu,  and 
also  all  the  triple  phosphate  set  free  by  the  alkali,  must  have 
been  allowed  completely  to  subside.  Next,  two  microscopic  slides 
of  glass,  of  the  ordinary  dimensions,  are  to  be  introduced,  with 
the  upper  end  of  one  slide  resting-  against  that  of  the  other,  and 
with  their  lower  ends  separated  as  far  as  the  width  of  the  phial 
will  permit;  and  lastly,  the  bottle  is  to  be  filled  up  with  a  solu- 
tion of  gum  arable  in  common  water,  one  ounce  of  which  will 
weigh  520  grains.  This  solution  must  also  be  perfectly  clear, 
having  been  first  strained  through  cloth,  and  then  left  to  stand 
for  some  days  to  allow  of  the  subsidence  of  all  the  floating  vege- 
table matter.  It  must  also  be  added  carefully  to  the  alkaline 
solution,  that  the  two  solutions  may  be  mixed  as  little  as  pos- 
sible in  this  part  of  the  process.  The  bottle  must  now  be  kept 
perfectly  still,  covered  with  a  piece  of  paper  to  prevent  the 
admission  of  dust,  for  three  weeks  or  a  month.  Time  would  be 
saved  by  having  a  dozen  bottles  thus  charged,  and  examining 
their  contents  at  stated  intervals,  according  to  the  chief  object 
sought  for  in  the  experiment.  The  soluble  salts  of  lime  to  be 
decomposed  by  the  subcarbonate  of  potash  are  contained  in  the 
gum,  in  combination  with  malic  acid,  and  also  in  the  common 
water;  ammoniaco-magnesian,  or  triple  phosphate,  is  also  con- 
tained in  the  gum,  and  is  set  free  by  the  alkali.  Muriate  of  lime, 
dissolved  in  a  solution  of  gum  from  which  all  the  lime  had  been 
previously  separated,  would  answer  a  similar  purpose,  provided 
the  muriate  were  not  in  too  great  excess  for  the  gum,  in  which 
ease  crystals  of  carbonate  would  be  formed  together  with  the 
globules,  and  the  surface  of  the  slide  would  become  covered  with 
coalescing  patches  of  the  latter.  Also  muriate  of  barytes,  and 
muriate  of  strontia,  when  treated  in  the  same  manner  as  the 
muriate  of  lime,  furnish  each  a  globular  carbonate,  the  spherical 
form  of  the  latter  being  particularly  perfect  and  beautiful.  But 
muriate  of  magnesia,  when  decomposed  in  the  same  manner,  and 
under  precisely  the  same  condition,  does  not  furnish  globules, 
but  crystals  of  carbonate  of  magnesia,  evincing  no  tendency  to 
become  globular. ' ' 

To  follow  his  methods  further  for  the  formation  of  large 
calculi,  such  as  are  seen  in  the  hard  secretions  of  the  pulps  of 
the  teeth,  would  take  up  too  much  space  to  be  included  in  this 
volume.  These  are  described  as  the  meeting  of  two  calculi, 
which  are  drawn  together  l)y  the  mutual  attraction,  and  the 
blending  of  two  into  one.    These  are  very  hard  bodies  and  the 


CALCIFICATIONS    OF    THE    DENTAL    PULP.  283 

blending  comes  through  disintegration  and  reformation  of  the 
two  into  one  body.  Others  are  added  in  the  same  way  and  the 
calculi  become  larger  and  larger.  Each  new  addition  blending 
with  the  calculi  previously  formed,  but  forming  a  ring  around 
the  calculi  until  many  such  rings  may  be  seen,  as  in  the  calculi 
we  sometimes  see  in  the  pulps  of  teeth. 

The  descriptions  of  these  artificial  formations  occupy  about 
half  the  book  and  the  other  half  is  devoted  to  a  description  of 
the  principles  illustrated  in  the  artificial  production  of  these 
calculi  to  the  formation  of  shells  of  the  moUusca,  of  the  bones  of 
lower  animals,  and  of  man. 

Authors  often  mention  in  their  reference  to  Rainey's  book 
the  name  of  Ord.  I  have  found  but  one  paper  on  this  subject 
written  by  Wm.  Ord  and  that  is  occupied  entirely  with  descrip- 
tions of  spherites  formed  from  cholestrin.  This  article  of  eight 
pages  appeared  in  the  Proceedings  of  the  Royal  Society  of 
London,  June,  1879,  p.  238.  He  describes  bodies  of  similar 
appearance  that  are  formed  from  cholestrin  found  in  the  gall 
bladder  and  in  tumors  of  various  kinds,  by  a  treatment  closely 
similar  to  those  described  by  Rainey  for  calculi.  This  paper  by 
Ord  seems  to  be  not  only  a  careful  and  close  description  of  these 
processes  but  it  is  worth  any  one's  while  to  read  it  as  a  bit  of 
scientific  literature.  He  mentions  experiments  by  Professor 
Guthrie,  who  formed  very  similar  bodies  from  the  salts  of  cop- 
per, which  have  the  appearance  of  true  copper,  but  are  in  fact  a 
combination  of  copper  and  a  colloid  substance.  None  of  these 
formations  are  true  crystals.  A  crystallization  seems  to  defeat 
entirely  the  result  sought.  This  crystallization  may  result  from 
impurities  of  the  chemicals  used  and  various  other  accidents. 
It  is  found  that  the  addition  of  magnesia  even  in  small  quan- 
tities causes  a  crystallization  instead  of  formation  of  calco- 
spherites  and  no  calco-spherites  seem  to  be  formable  in  a  flui<l 
which  contains  magnesia. 

Importance  of  studies  of  calco-spherites. 

This  fact  will  probably  become  important  in  the  studies  of 
what  have  been  called  ''mottled  teeth,"  in  which  there  is  a  fail- 
ure of  formation  of  the  cementing  substance  of  the  enamel,  often 
accompanied  by  a  discoloration  of  the  areas  from  which  the 
cementing  substance  is  missing.  These  mottled  teeth  have  been 
found  in  the  mouths  of  as  high  as  eighty-five  per  cent  of  persons 
living  in  certain  localities  during  the  jieriod  of  the  forinntion  of 
the  enamel. 


284  SPECIAL    DENTAL    PATHOLOGY. 

When  wo  consider  that  as  a  matter  of  fact  the  teeth  and 
bones  are  formed  by  combination  of  calcium  salts  with  colloids, 
from  which  we  may  dissolve  the  calcium  salts,  leaving  the  col- 
loids in  the  soft  state,  we  see  the  widespread  importance  of  a 
closer  study  of  this  subject.  There  is  no  true  crystallization  in 
the  formation  of  these  calco-spherites,  or,  so  far  as  I  am  able  to 
gTasp  it,  in  the  formation  of  the  bones,  dentin  or  enamel.  Tn  the 
calco-spherites  the  polaroscopical  appearance  is  limited  to  the 
formation  of  a  dark  cross  which  is  very  characteristic  of  these 
bodies.  The  formation  of  indefinite  bright  spots  and  limited 
indefinite  lines  will  also  be  found  in  the  cut  specimens  of  calco- 
spherites,  dentin  and  enamel;  and  to  a  more  limited  degree  in 
the  bones,  but  there  is  no  true  polarization  with  decompositions 
of  light,  as  will  be  seen  in  many  of  the  true  crystals.  There  are 
crystals  which  will  decompose  light  into  its  component  colors 
and  crystals  which  will  not  do  so. 

I  may  say  that  I  have  been  attracted  to  the  study  of  these 
old  experiments  because,  as  has  been  stated  previously,  globulin 
already  loaded  with  calcium  salts  (calco-globulin  in  fact)  comes 
into  the  mouth  with  the  saliva,  and  is  formed  into  salivary  cal- 
culus, and  also  globulin  that  has  apparently  no  calcium  salts  in 
its  make-up  comes  into  the  mouth  and  is  not  formed  into  salivary 
calculus. 

To  my  mind,  Rainey's  book  is  a  study  of  one  such  combina- 
tion of  lime  salts  with  colloid  material,  and  Ord  and  others  who 
have  written  along  the  same  lines,  have  presented  a  few  other 
similar  combinations.  The  chemical  tendencies  to  the  comlnna- 
tion  of  these  for  the  formation  of  hard  substances  from  salts 
and  colloid  material  should  not  be  ignored  in  our  study  of  these 
processes.  These  chemical  processes  must  be  regarded  as  under 
the  control  of  the  cellular  elements,  which  determine  the  specific 
forms  to  be  produced.  The  calco-spherite  is  formed  when  the 
elements  are  brought  together  and  by  some  accident  have  fallen 
out  of  this  control  and  are  left  to  the  chemical  affinities  of  the 
substances  uniting. 

When  we  turn  our  attention  to  the  life  force  as  a  controlling 
entity  in  the  production  of  animal  bodies,  we  must  at  once  con- 
cede that  the  material  coming  imder  this  influence  is  controlled 
in  its  chemistry  in  the  main  l)y  the  manipulation  of  these  life 
forces,  and  material  is  withheld  or  added  in  proportion  to  the 
substance  which  the  life  force  indicates.  Hence,  we  get  the 
extremely  hard  enamel  or  the  softer  bone,  or  the  dentin  lying 
between,  and  various  other  hard  substances  formed  in  this  way. 


CALCIFICATIONS    OF    THE    DENTAL   PULP.  285 

In  this  view  of  the  case  the  calco-spherite  would  seem  to  bo 
in  some  degree  related  to  a  cyst,  hedged  about  by  a  membrane, 
which  develops  for  the  purpose.  The  calco-spherite,  however, 
has  no  such  membrane  that  has  yet  been  discovered,  but  lies 
among  the  tissues  separate  from  control  of  the  life  forces  which 
act  upon  these  materials  in  the  formation  of  definite  tissues. 
Therefore,  this  material  is  left  to  form  its  chemical  affinities 
uncontrolled  by  the  life  force.  This  play  of  chemical  affinities 
was  the  particular  thing  which  Rainey  studied;  other  things 
were  incidental. 

This  consideration  of  the  subject  would  open  a  very  wide 
field  for  discussion,  but  an  expansion  of  this  would  be  somewhat 
foreign  to  this  book.  There  are  some  things  which  I  have  men- 
tioned, as  have  others,  indicating  that  the  colloids  are  the  agents 
used  in  the  building  of  bone  and  very  hard  substances,  or  that 
calco-globulin,  in  the  form  in  which  it  exists  in  the  tissues,  is 
such  an  agent,  supplying  both  the  hard  material  and  the  soft. 
These  are  manipulated  under  the  influence  of  life  direction  in 
or  among  the  cells  which  accomplish  the  change. 

I  have,  myself,  seen  many  very  small  spherules  l.ying 
between  the  odontoblasts  and  the  forming  dentin  in  sections 
taken  during  the  development  of  the  teeth.  Andrews,  in  his 
article  in  the  American  Text-Book  of  Operative  Dentistrj^,  p.  70, 
describes  certain  minute  glistening  bodies,  occurring  about  the 
cells  of  the  ameloblastic  layer  of  the  enamel  organ.  My  inter- 
pretation is  that  these  are  in  fact  primarj^  spherules  of  calco- 
globulin,  of  unusually  small  size.  They  are  certainly  not 
calco-globulin  in  the  sense  of  calco-spherites  Imown  in  the  hard 
formations  in  the  tooth's  pulp.  The  naming  of  them  by 
Dr.  Andrews  as  calco-spherites  seems  to  me  to  be  a  mistake. 
They  are  probably  properly  distinguished  as  calco-globulin. 

Figure  340  illustrates  an  unusual  formation  found  within  the 
pulp  tissue ;  Figure  341  a  calco-spherite-like  formation  found  in 
the  peridental  membrane. 


S7 


28G  SPECIAL   DENTAL   PATHOLOGY, 


TEGHNIG  OF  TREATMENT  OF  THE 
DENTAL  PULP 

ILLUSTRATIONS:    FIGURES  342-401. 

IN  my  work  on  Operative  Dentistry,  I  presented  only  the 
technic  of  exposure  and  removal  of  the  dental  pulp,  and  filling 
of  root  canals.  In  reviewing  that  writing  at  this  time,  I  find 
practically  nothing  which  I  desire  to  change.  I  have,  therefore, 
decided  to  include  most  of  it,  with  the  illustrations,  as  it  appears 
in  the  Operative  Dentistry,  adding  that  which  seems  necessary 
to  a  complete  presentation  of  the  subject  of  pulp  treatment  in 
this  book. 

GENERAL    CONSIDERATIONS. 

There  are  certain  general  propositions  which  are  common 
to  almost  all  operations  which  involve  the  opening  and  treatment 
of  pulp  chambers  and  root  canals.  These  will  be  presented  first. 
In  this  connection,  the  dentist  should  hold  foremost  in  mind  the 
fact  that  the  tissue  of  the  pulp  can  not  be  considered  as  separate 
and  apart  from  the  other  tissues  of  the  body;  that,  in  the  mat- 
ter of  transmission  of  infection,  the  pulp  bears  the  same  relation 
to  the  general  system  as  do  other  tissues.  Therefore,  in  the 
treatment  of  the  pulp,  surgical  cleanliness  is  quite  as  important 
as  in  the  treatment  of  other  parts.  The  field  of  operating  should 
have  the  same  consideration  as  to  asepsis;  all  broaches,  other 
instruments  and  dressings  should  be  sterile;  the  dentist  has  no 
more  license  to  use  an  unsterile  broach  than  has  a  surgeon  to 
deliberately  operate  with  an  infected  knife.  The  far-reaching, 
serious  and  many  times  fatal  consequences  of  infections  enter- 
ing the  system  through  root  canals  demand  that  we  give  our 
patients  the  same  protection  which  they  receive  at  the  hands  of 
the  surgeon.  The  technic  for  asepsis  which  will  be  presented  is 
simple ;  it  may  be  easily  carried  out  to  the  last  detail  by  every 
practitioner. 

We  should  always  approach  the  treatment  of  a  pulp  with  a 
full  appreciation  of  the  fact  that  the  continued  usefulness  of  the 
tooth  is  dependent  upon  the  success  of  the  effort.  Thorough- 
ness in  this  class  of  operations  is  absolutely  essential  to  success. 


TREATMENT    OF    THE    DENTAL   PULP.  287 

A  good  knowledge  of  the  anatomy  of  the  teeth  and  a  large  store 
of  patience  are  necessary  to  thoroughness.  If  there  is  a  single 
class  of  operations  in  dentistry  which  deserves  the  most  con- 
scientious efforts  of  which  each  operator  is  capable,  it  is  the 
treatment  of  root  canals.  The  knowledge  that  an  improperly 
treated  canal  may  not  give  serious  trouble  for  many  years  has 
doubtless  led  to  much  carelessness  and  even  recklessness  in  this 
operation.  The  advent  of  the  X-ray  has  shown  this  very  posi- 
tively. Now  that  we  are  confronted  with  the  fact  that  each  error 
in  this  technic  may  endanger  the  life  of  the  patient,  it  is  impera- 
tive that  every  dentist  should  devote  whatever  of  time  and  study 
may  be  necessary  to  gain  the  highest  possible  degree  of  efficiency. 

Thoroughness  in  root  canal  treatment  requires  time.  It 
often  requires  that  the  operator  be  in  the  best  possible  physical 
and  mental  condition.  While  one  may  not  always  be  able  to 
control  the  time  of  doing  these  things,  they  should  generally  be 
set  for  the  first  morning  appointments,  particularly  for  the  final 
inspection  of  the  canals  and  the  placing  of  root  fillings.  When- 
ever the  operator  is  uncertain  of  the  conditions  within  the  canal, 
either  as  to  the  removal  of  the  last  remnant  of  pulp  tissue,  or 
the  probability  of  getting  a  filling  well  to  the  apex,  a  dressing 
should  be  sealed  in  and  the  patient  given  another  appointment. 
In  the  more  difficult  cases  one  should  not  continue  at  any  sitting 
if  he  feels  that  he  is  not  making  progress. 

One  other  word  which  applies  to  all  pulp  treatment.  We 
have  not  been  sufficiently  careful  in  educating  the  public  to  a 
proper  appreciation  of  the  difficulties  presented  in  this  service, 
the  niceties  of  technic  required,  and  the  importance  of  it  to  the 
future  usefulness  of  the  teeth  and  to  the  general  health.  These 
are  things  which  our  people  should  know;  which  they  must 
understand,  if  we  are  to  have  their  cooperation  to  the  end  that 
we  may  take  the  time  necessary  to  do  the  operations  in  the  most 
painstaking  manner,  and  that  we  may  be  properly  and  willingly 
recompensed  for  such  service. 

Asepsis. 

The  first  rule  of  modem  surgery  is  asepsis.  As  applied  to 
pulp  treatment  this  means  that  the  field  of  operation  should  be 
treated  as  though  it  were  a  surgical  wound.  The  immediate 
neighborhood  should  be  maintained  in  an  aseptic  condition  dur- 
ing each  operation.  Nothing  carrying  infection  should  be  per- 
mitted to  enter  this  field.  All  instruments  and  dressings  should 
be  unquestionably  sterile.    In  no  case  should  saliva  be  allowed  to 


288  SPECIAL    DENTAL   PATHOLOGY. 

enter  a  pulp  chamber  from  the  begiimmg  of  the  first  treatment 
until  after  the  root  canals  are  filled.  This  may  be  done  by  so 
simple  a  technic  that  there  is  no  reason  why  it  should  not  be 
carried  out  to  the  finest  detail,  except  in  a  very  limited  number 
of  cases  which  present  unusual  difficulties. 

Plan  for  aseptic  technic.  It  should  be  recognized  that  it 
is  impractical,  although  not  impossible,  for  the  dentist  to  keep 
his  hands  surgically  clean  during  pulp  treatments.  However, 
a  safe  technic  may  be  employed  by  which  ordinary  cleanliness  of 
the  hands  will  be  sufficient  in  most  cases.  In  other  words,  a  plan 
may  be  carried  out  by  which  the  operator's  fingers  will  not  touch 
anything  which  actually  enters  the  pulp  canal,  or  the  aseptic 
field,  not  even  with  the  cotton  wrapped  on  broaches.  Under  this 
plan,  asepsis  in  pulp  treatment  requires:  (1)  That  the  rubber 
dam  be  applied  for  every  treatment,  and  in  such  manner  that 
there  will  be  no  leakage  of  saliva ;  (2)  that  the  field  of  operation 
—  all  teeth  included  in  the  rubber,  and  the  adjacent  inibber  —  be 
rendered  sterile  by  swabbing  with  an  antiseptic  l)efore  the  pulp 
chamber  is  opened;  (3)  that  all  broaches,  burs,  excavators  and 
dressings  which  enter  the  pulp  chamber  shall  be  sterile ;  (4)  that 
the  fingers  be  surgically  clean,  if  they  come  in  contact  with  cot- 
ton which  is  to  enter  the  canal,  or  the  aseptic  field. 

Application  of  the  eubbee  dam.  It  would  seem  that  no 
argument  should  be  required  to  convince  any  thoughtful  person 
of  the  absolute  necessity  of  applying  the  rubber  dam  for  the  pur- 
pose of  maintaining  asepsis  while  a  pulp  chamber  is  open.  It  is 
necessary  to  keep  the  saliva  from  entering  a  canal,  not  only 
because  the  saliva  is  loaded  with  many  varieties  of  micro- 
organisms, but  also  because  it  contains  material  which  will  cause 
the  discoloration  of  the  tooth  if  permitted  to  be  absorbed  into 
the  dentinal  tubules. 

It  is  just  as  important  that  the  rubber  be  applied  in  cases 
presenting  with  the  pulp  dead  and  the  pulp  chamber  widely 
open,  as  in  cases  in  which  the  pulp  is  not  exposed.  The  fact  that 
the  pulp  tissue  is  already  infected  is  not  a  reason  for  omitting 
to  apply  the  dam.  There  is  the  same  danger  in  treating  such  a 
tooth  without  applying  the  rubber  dam  and  following  rigid  rules 
of  asepsis  as  there  would  be  if  a  surgeon  should  use  unsterile 
instruments  and  dressings  in  an  infected  wound.  As  will  be 
pointed  out  later,  many  chronic  alveolar  abscesses  are  caused  by 
failures  to  observe  the  rule  relative  to  the  application  of  the 
rubber  dam.     The  rubber  dam  should  remain  in  place  at  each 


TREATMENT    OF    THE    DENTAL    PULP.  289 

sitting  until  after  the  cavity  in  the  tooth  has  been  securely 
sealed. 

Sterilization  of  field.  After  the  rubber  is  in  place,  the 
field  of  operation  should  be  rendered  sterile  by  swabbing  the 
crowns  of  the  teeth  included  in  the  rubber,  also  the  adjacent 
rubber,  with  an  antiseptic,  such  as  oil  of  cloves.  Then  the  field 
may  be  dried  with  alcohol.  This  should  be  done  on  each  occa- 
sion before  the  pulp  chamber  is  opened.  If  a  temporary  filling- 
has  been  placed  at  a  previous  sitting,  it  should  not  be  removed 
until  the  rubber  is  on  and  the  field  sterilized.  If  the  cavity  is  a 
proximal  one,  a  thin  saw  may  be  carried  past  the  contact,  thus 
trimming  off  enough  of  the  temporary  filling  to  permit  the  appli- 
cation of  the  rubber,  without  disturbing  the  filling. 

Sterilization  of  instruments,  dressings,  etc.  The  thor- 
ough sterilization  of  all  instruments  entering  the  pulp  chamber 
may  be  easily  done  by  using  two  small  dishes  of  suitable  size, 
one  containing  95  per  cent  phenol,  the  other  absolute  alcohol. 
The  accompanying  illustration.  Figure  344,  shows  a  special  dish 
designed  for  this  purpose,  containing  one  depression  the  proper 
size  for  the  immersion  of  a  broach,  bur,  or  other  instrument,  in 
phenol,  and  the  other  to  hold  a  sufficient  quantity  of  alcohol. 
The  broach  may  be  fully  immersed  in  the  phenol  for  a  few  min- 
utes, then  picked  up  with  the  pliers  and  washed  in  alcohol. 
After  it  has  been  placed  in  the  broach  holder,  the  end  of  the 
broach  may  be  dipped  into  the  phenol  and  washed  in  the  alcohol 
as  frequently  as  may  be  desired  during  the  progress  of  the 
operation.  Burs  and  excavators  may  be  sterilized  in  the  same 
manner.  Gutta-percha  points  should  also  be  immersed  in  the 
phenol  and  alcohol  after  they  have  been  attached  to  the  root 
canal  plugger. 

Sterilization  of  broaches  wrapped  with  cotton.  To  avoid 
the  necessity  of  having  the  fingers  surgically  clean  in  order  that 
a  broach  may  be  wrapped  with  sterile  cotton,  the  cotton  should  be 
wrapped  upon  the  broach  and  then  sterilized.*  To  do  this  with- 
out inconvenience  requires  that  one  have  a  simple  dry  sterilizing 
oven,  and  all-metal  broach  holders  which  will  not  be  injured  by 
the  heat  of  the  sterilizer,  in  sufficient  number  that  a  few  will 
always  be  ready.  Such  a  sterilizer  is  shown  in  Figure  342. 
This  is  an  oven  made  of  asbestos  board,  fitted  with  a  single 
sixteen-candle-power  lamp  to  heat  it,  regulated  by  a  thermostat 

*  So  far  as  I  know,  the  first  publication  of  a  plan  of  sterilizing  broaches  wrapped 
with  cotton  was  in  a  paper  entitled,  "  The  Surgical  Treatment  of  Pulp  Canals  as  a 
Prevention  of  Systemic  Disturbances,"  by  Dr.  Elmer  S.  Best,  in  the  Dental  Review, 
Vol.  29,  1915,  p.  320. 


290  SPECIAL   DENTAL   PATHOLOGY. 

similar  to  that  described  in  Figures  173,  174  and  175,  for  the 
warm-water  tank.  A  thermometer  registers  the  temperature. 
This  oven  is  provided  with  porceLain  trays,  each  of  which  holds 
six  broaches;  also  dishes  for  cotton.  (See  Figure  343.)  Such 
an  oven  may  be  made  of  sheet  metal,  and  it  is  not  necessary  that 
the  temperature  be  controlled  by  a  thermostat.  One  may  take 
a  small  metal  box,  i3lace  a  lamp  inside,  and  after  a  little  experi- 
menting, determine  the  time  required  for  sterilization. 

The  oven  referred  to  will  hold  twenty-four  broaches,  in  four 
trays,  also  several  dishes  for  cotton  pellets  of  diiferent  sizes. 
Cotton  is  wrapped  on  the  broaches,  they  are  placed  in  the  trays 
and  these  are  placed  in  the  sterilizer.  The  temperature  of  the 
oven  is  kept  at  160°.  The  current  is  not  turned  off  at  night,  but 
is  left  on,  except  as  the  thermostat  disconnects  it.  Barbed 
broaches  are  not  placed  in  the  sterilizer;  they  are  immersed  in 
phenol  and  alcohol,  as  previously  mentioned. 

When  a  pulp  treatment  is  undertaken,  one  of  the  trays  con- 
taining six  wrapped  broaches  and  one  or  two  dishes  of  cotton 
pellets  of  different  sizes  are  placed  on  the  operating  tray  for  use. 
Afterward  those  not  used  are  returned  to  the  oven.  Figure  343 
shows  the  operating  tray  with  the  various  dishes,  instruments, 
etc.,  laid  upon  it.  Figures  345  and  346  illustrate  a  very  con- 
venient dropper  bottle. 

Technic  of  weapping  cotton  on  a  bkoach.  If  it  is  desired 
that  the  cotton  adhere  to  the  broach,  a  few  shreds  should  be 
pulled  between  the  fingers  until  there  are  but  a  few  parallel 
fibers.  One  end  of  these  should  be  held  between  the  forefinger 
and  thumb  of  the  right  hand  and  with  it  the  broach  should  be 
grasped  at  midlength,  or  with  a  cotton  wisp  extending  slightly 
past  its  point.  With  the  left  hand  the  other  end  of  the  cotton 
wisp  and  the  point  of  the  broach  should  be  grasped  together,  and 
the  ])roach  rotated  in  the  fingers  of  the  right  hand  until  the  cotton 
is  wrapped  firmly  upon  its  shaft.  AVhen  tliis  is  properly  done, 
the  cotton  will  cling  firmly  to  the  broach  and  is  not  likely  to  be 
lost  in  the  canal. 

If  it  is  desired  to  place  a  dressing  in  the  canal,  a  wisp  of 
cotton  should  be  formed  with  its  fibers  mostly  parallel,  and  the 
end  of  this  caught  with  the  point  of  the  broach  with  the  thumb 
and  finger  of  the  left  hand  and  the  broach  rotated  with  the  right 
hand,  while  the  fingers  of  the  left  roll  the  cotton  on  its  end.  In 
this  way  the  cotton  is  rolled  on  the  broach  in  such  a  way  that  it 
will  not  slip  backward  on  the  l)roach  and  can  be  carried  to  the 


Fig.  342. 


Fig.  342.  A  sniall  dry  stcrili/.iiig  ovon  iu'sitcd  li.v  ;n:  clct'tric  liiiiip,  I'oiit rolled  by 
a  thermostat.  This  oven  holds  four  porcelain  trays,  caili  cuiitaiiiiiio;  six  l)roaelies  iu 
the  liandles.  Cotton  is  wrapped  on  the  broaeiies  before  ])iaeiii}j  them  in  the  sterilizer. 
There  is  also  room  for  other  small  trays  containinjj  cotton  pellets,  etc.  This  oven  is 
kept  at  160°  and  the  material  to  be  sterilized  is  left  in  the  oven  several  hours 
before  it  is  used.     One  of  the  broatdi  trays  and  the  little  porcelain  trays  for  cotton 


pellets  are  shown  in  Figure  343. 
1 75. 

This  o\en  is  made  of  /'..-inch 
wiiji',  !l-"'s  inches  liigh,  and  '.\  inch 
door  is  not  shown. 


The  thernuistat    is   illustrated   in    Figures    173,   174, 


■fbeslos 
deep 


TJK 


(■tell 


Inal 
half 


(ia 


1    inchi's 


*27 


Fig.  343. 


Fig.  344. 


Fig.  343.  Operating  tray  equipped  for  pulp  treatineiit.  Two  porccljiin  tniy.s 
••oiilain  sterile  cotton  pellets;  the  larjjer  poreelain  tniy  contains  six  broach  holders  aiid 
hronclies,  with  sterile  cotton  wrapped  on.  These  have  ;jnst  Ix'en  reniove<l  from  the  dry 
sterilizer.  The  glass  slab  for  sterilizing  broaches  is  better  shown  in  Figure  344.  Two 
of  the  small  square  porcelain  trays  contain  medicaments,  the  tiiird  gutta-percha 
points. 

Fig.  344.  Glass  slab  for  sterilizing  broaches  and  other  instruments  used  in  pulp 
treatments.  The  depression,  a.  a,  is  filled  with  ninety-five  per  cent  phenol;  c  is  filled 
with  alcohol,  using  the  dropper  bottles  shown  in  Figures  34.5,  346.  Broaches  or  burs 
may  be  inmiersed  in  the  phenol,  then  picked  up  with  the  pliers  (b  is  more  deeply 
recessed  for  this  purpose)  and  washed  in  alcohol.  Broaches  may  be  resterilized  as 
often  as  desired  during  the  operation. 


Fig.  345. 


Fig.  346. 


Figs.   345,   31C).      A    very   coiivoniciit  ilrniiprr   iMittIc    (icsii,nic(l    \>y    tlir    h\\' 

Austin   Dunn.      Afirr  i-.\\>  is  rcnuivcil  uihI  the  ImiHIc  tipipcd   forwani,  as  in    Fij; 

slight   i)ressui-p  un  tiic  bulb  t'urces  out  a  lirop  at   a  time. 

27b 


Dr.   .1. 


Fifi    .^47     P)f ocliwood  r.i'oosote 


Fig.  :U8.    Oil  of  Tloves 


Pifi.   .'^49.    (  )il   uf  »  iiiiiatiioii 


Fig.  350.     ••i_2— 3'' 


Fig.    351.    Crpsol   an. I    I'minal 


l''i(,.    352     L'li'sol   ami    Foiniali 


TREATMENT    OF    THE    DENTAL    PULP.  291 


Figs.  347  to  351.  Direct  color  photographic  reproductions  of  portions  of  fore- 
arms upon  which  various  antiseptics  were  sealed  under  rubber  covers  for  forty-eight 
hours,  to  determine  their  effect  upon  the  tissues.  In  each  instance  a  small  pellet 
of  cotton  was  moistened  with  three  drops  of  the  medicament  and  this  was  sealed 
on  under  a  piece  of  rubber  dam,  as  shown  in  Figure  353.  The  photographs  were 
taken  immediately  after  the  removal  of  the  applications,  which  were  placed  on  the 
arms  of  members  of  the  class  of  1915,  Northwestern  University  Dental  School. 

Fig.  347.  Beechwood  creosote.  There  was  no  discomfort,  and  when  the  drug 
was  removed  the  skin  appeared  to  be  very  slightly  stained. 

Fig.  348.  Oil  of  cloves.  There  was  no  discomfort,  and  within  two  minutes  after 
the  application  was  removed  the  spot  could  not  be  seen.  There  is  some  discoloration 
of  the  portion  of  the  arm  in  the  lower  part  of  the  illustration;  this  was  caused  by  the 
adhesive  strip. 

Fig.  349.  Oil  of  cinnamon.  There  was  marked  inflammation.  A  large  blister 
formed  and  burst  within  thirty-six  hours. 

Fig.  350.  "  1-2-3."  This  caused  a  slight  irritation  and  there  was  one  little 
blister  when  it  was  removed. 

Figs.  351,  352.  Cresol  and  formalin.  All  of  the  arms  to  which  this  drug  was 
applied  were  painful;  one  student  removed  the  application  after  seven  hours.  These 
two  fairly  represent  the  inflammation  resulting  from  a  forty-eight-hour  application. 
These  centers  were  yellow  and  looked  as  though  the  tissue  would  slough  off,  but  it  did 
not.  Two  months  later,  induration  was  still  present  and  the  dead  tissue  was  being 
gradually  thrown  off  in  scab  after  scab. 


270 


292  SPECIAL   DENTAL   PATHOLOGY. 

apical  end  of  the  canal ;  and  when  the  broach  is  withdrawn,  the 
cotton  will  remain  in  the  canal. 

Surgically  clean  fingers.  Even  with  the  equipment  above, 
it  will  occasionally  be  necessan^  at  the  time  of  operating  to  use 
the  fingers  in  wrapping  a  broach.  For  this  very  small  quanti- 
ties of  cotton  are  placed  in  little  envelopes  and  sterilized  in  the 
oven.  One  of  these  may  be  stuck  into  a  slot  in  the  operating 
tray  shown  in  Figure  343,  and  the  end  cut  off  with  the  scissors, 
so  that  the  cotton  may  be  reached  either  with  the  pliers  or 
fingers.  The  hands  should  be  thoroughly  scrubbed  and  then 
immersed  in  an  antiseptic  solution  before  the  cotton  or  other 
aseptic  material  is  touched. 

The  carrying  out  of  these  simple  plans  of  asepsis  presents 
no  difficulties  nor  delays,  if  the  necessaiy  equipment  is  at  hand 
and  conveniently  arranged. 

Sealing  treatments. 

The  material  used  for  sealing  treatments  should  be  abso- 
lutely impervious  to  penetration  by  the  fluids  of  the  mouth;  it 
should  hermetically  seal  the  cavity ;  it  should  be  easy  of  manipu- 
lation ;  it  should  be  sufficiently  hard  to  withstand  the  stress  of 
mastication  without  very  much  wear ;  it  should  be  easily  remov- 
able from  the  cavity  when  desired.  Pure  base-plate  gutta-percha 
is  the  only  material  I  know  which  meets  these  requirements. 
The  so-called  temporary  stoppings  contain  so  much  wax  that 
they  are  too  soft  to  be  dependable.  Careful  experiments  con- 
ducted in  my  laboratory  by  Dr.  George  C.  Poundstone*  have 
shown  that  the  oxyphosphate  cements  can  not  be  generally  relied 
upon  as  being  impervious  to  moisture.  This  is  also  shown  by 
the  number  of  teeth  which,  discolor  when  cement  is  used  as  a 
sealing  agent  for  a  considerable  time.  Another  objection  to 
cement  is  the  difficulty  of  removing  it.  If  tihe  cement  has 
become  thoroughly  hard,  it  often  requires  much  cutting  with  a 
bur.  This  is  usually  an  unpleasant  procedure  for  the  patient, 
and  may  be  very  painful  if  the  tooth  is  tender  to  pressure. 

Technic  of  sealing  treatments  with  base-plate  gutta- 
percha. The  teclmic  of  placing  a  filling  of  base-plate  gutta- 
percha is  simple,  but  the  rules  must  be  followed  very  exactly  to 
insure  success.     It  is  essential  in  the  first  place  that  the  cavity 

•  Microscopic  Study  of  Cements,  Transactions  Illinois  State  Dental  Society,  1904, 
p.  82;   Dental  Digest,  Vol.  XI,  1904.  p.  1. 

Cements.  Transactions  Illinois  State  Dental  Society,  1905,  p.  136;  Dental  Review, 
Vol.  19,  1905.  p.  802. 

Cement  Problem  in  Inlay  Work,  read  bcfnro  Fourth  International  Dental  Congress, 
1904,  Dental  Cosmos,  Vol.  47,  1905,  p.  756. 


TREATMENT    OF    THE    DENTAL   PULP.  293 

should  be  cut  to  reasonably  good  form  for  the  retention  of  the 
gutta-percha  filling.  The  pulp  being  involved,  the  cavity  is 
necessarily  of  some  depth  and  it  will  usually  require  very  little 
additional  cutting  to  give  sufficiently  good  retention  form. 

The  rubber  dam  should  be  on  and  the  cavity  thoroughly  dry. 
The  walls  should  then  be  slightly  moistened  with  a  eucalyptol* 
which  will  dissolve  gutta-percha.  This  will  soften  the  gutta- 
percha which  comes  in  contact  with  the  walls  so  that  it  will 
adhere.  The  gutta-percha  should  be  warmed  until  it  is  quite 
soft  and  pliable.  Care  should  be  taken  not  to  overheat  it,  as  it 
will  not  again  become  as  hard  as  it  otherwise  would.  If  the 
cavity  is  small,  the  filling  may  be  made  of  a  single  piece,  but  for 
most  cavities  it  will  be  best  to  use  several  small  pieces,  placing 
each  one  and  packing  it  carefully  with  as  large  a  flat-end  instru- 
ment as  can  be  used  in  the  cavity.  I  prefer  to  use  amalgam 
pluggers,  wliich  have  flat,  serrated  ends.  The  direction  of  the 
force  should  be  toward  the  walls,  the  same  as  in  packing  gold. 
Additional  pieces  should  be  added  until  the  cavity  is  full.  All 
of  the  packing  should  be  done  with  cold  instruments.  Then 
with  a  flat  burnisher,  heated  sufficiently  that  it  will  readily  cut 
the  gutta-percha,  the  filling  should  be  trimmed  to  form.  The> 
movements  of  the  hot  burnisher  should  generally  be  toward  the 
margins.  If  the  burnisher  is  not  heated  sufficiently,  it  will  drag 
in  the  gutta-percha  and  loosen  it.  It  must  be  hot  enough  so  that 
it  may  be  carried  through  the  gutta-percha  with  a  quick  stroke. 
^Vhen  the  trimming  is  done  in  this  way,  the  mass  of  gutta-percha 
will  not  be  heated  sufficiently  to  cause  pain. 

In  proximo-occlusal  cavities,  the  septal  tissue  should  be  pro- 
tected by  holding  the  blade  of  a  finishing-knife,  or  other  suitable 
instrument  against  the  tooth  at  the  position  of  the  gingival  wall. 
This  will  prevent  the  gutta-percha  from  being  crowded  against 
the  soft  tissue. 

If,  in  the  sealing  of  a  treatment  with  gutta-percha,  it  is 
desired  to  avoid  pressure,  a  piece  of  stiff  writing-paper  may 
be  laid  in  the  cavity  and  covered  with  a  layer  of  cement,  or  a 
piece  of  sheet  metal  —  copper,  German  silver  or  steel  —  may  be 
placed  first,  and  the  gutta-percha  sealing  placed  over  it.    When 

*  There  are  some  thirty-odd  species  of  eucalyptus  trees,  each  of  which  furnishes 
an  oil,  but  these  oils  differ  very  widely.  Some  will  dissolve  gutta-percha  very  readily; 
others  will  not  dissolve  it  at  all.  Only  those  which  dissolve  gutta-percha  readily 
should  be  used  for  this  purpose.  The  oil  may  be  tested  by  dipping  a  gutta-percha  cone 
into  it  and  then  rolling  the  cone  between  the  fingers.  Tf  the  oil  dissolves  the  gutta- 
percha readily,  the  fingers  will  be  smeared  with  gutta-percha,  and  this  will  adhere  very 
tenaciously  to  the  skin.  Tf  the  oil  does  not  dissolve  the  gulta-percha,  it  should  bo  dis- 
carded and  search  made  for  an  oil  which  will. 


294  SPECIAL   DENTAL   PATHOLOGY. 


Figs.  353  to  358.  Keproductions  of  photographs  of  portions  of  forearms  upon 
which  antiseptics  were  sealed  under  rubber  covers  for  forty-eight  hours,  to  determine 
their  effect  upon  the  tissues.  Applications  were  applied  to  arms  of  members  of  the 
class  of  1915,  Northwestern  University  Dental  School. 

Fig.  353.  Method  of  applying.  A  pellet  of  cotton  was  moistened  with  three 
drops  of  the  drug  and  applied  directly  to  the  arm.  This  was  covered  by  a  piece  of 
rubber  dam  and  sealed  with  adhesive  plaster.    It  was  removed  after  forty-eight  hours. 

Fig.  354.     Oil  of  cloves.    There  was  no  appreciable  inflammation. 

Fig.  355.  Oil  of  cinnamon.  This  is  the  same  arm  as  shown  in  Figure  349.  A 
large  blister  formed  and  the  surface  tissue  was  destroyed. 

Fig.  356.  Oil  of  cassia.  The  area  was  a  brownish  red.  Neither  the  pain  nor 
the  inflammation  were  as  severe  as  reported  by  Dr.  Peck  in  1898,  doubtless  due  to  the 
difference  in  the  purity  of  the  oils.  In  fact,  the  oil  used  in  this  experiment  was 
probably  not  cassia,  although  it  was  claimed  to  be  a  cassia  oil  from  China. 

Figs.  357,  358.  Cresol  and  formalin.  The  photographs  of  these  two  arms  were 
taken  seven  days  after  the  application  was  removed.  Figure  358  shows  three  pins 
which  were  pushed  in  8  mm.  (nearly  %  of  an  inch)  before  any  sensation  was  felt. 
This  arm  looked  practically  the  same  two  months  later. 


V\a.   .■!.").'I.      A|)|ilii',i  tidii. 


W[(,.  :i.")4.     ( )il  III'  cloves. 


i''i<,.  ;i.'j.'i.    ( )ii  (.r  (• 


I  iiii;i  iiioii. 


Fig.   ;!.")(;.      (  )il    n\'   cnssi: 


Flu.    .''>.")7.      ( 'rcsul    ;iii(|    l'iii'iii;i  I  in 


l'''l(i.    .''i.'iS.       (  'iTsiil    ;i  11(1     rdiiiKi  li  II 


Fig.  359. 


Fir;.  :ir)!t.  Diagrain  of  a  l)iciispiil  tuoth  sjilit  buceo-lingually,  showing  the  direc- 
tions (if  liie  eiiaiiiel  rods  in  (lie  liirfctcnt  parts  of  the  plane  of  the  cut.  Thv 
recessional   lines  of  the  horns  of  the  iMilp  ;irt'   shown   hy  the  dotted   lines. 


Fig.  360. 


J-'k,.  :;(ii. 


Fig.  362. 


seco^^,£  afS;r';'at:'"'""  ''^•"''"^'  '"-^^"'"'^  ^^"^^  "^  ^^•^'•"'^  bicuspid  and 

Fig.    362.      Radiograph    showing    partially    dovolopod    roots    of   second    niul-.r    -.t 
fifteen  years;    also  a  very  good  root  tilling  in  the  first  molar.  ^ 


9  to  12  10  to  13  14/11/16  14 10 16  '*<»'6  'Ot'l* 


15  toll  18 to  21 


Fig.  ?,(i^.  A  (liaj^raiiiniatie  roprescntation  of  tlic  ealcififation  of  the  permanent 
teeth.  The  teeth  of  the  left  side  of  the  upper  jaw  are  represented  in  outline.  Below 
each  tooth  a  figure  is  placed  which  represents  the  average  year  of  the  eruption  of 
that  tooth.  Upon  each  tooth  figvires  are  placed  at  intervals  representing  the  date,  in 
years,  of  the  progress  of  its  calcification  to  that  time.  The  relation  of  the  progress 
of  calcification  between  the  different  teeth,  or  the  contemporaneous  calcification  lines, 
may  be  found  by  following  any  individual  figure  from  tooth  to  tooth.  The  figure  7, 
for  instance,  is  at  the  junction  of  the  middle  and  gingival  thirds  of  the  root  of  the 
central  incisor  and.  reading  from  left  to  right,  it  gradually  drops  down  to  a  little 
below  midlength  of  the  crown  of  tho  second  bicuspid :  it  then  jumps  to  about  half 
length  of  the  root  of  the  first  molar;  then  back  to  the  junction  of  the  occlusal  and 
middle  thirds  of  the  crown  of  the  second  molar;  it  does  not  appear  at  all  on  the 
third  molar.  Any  other  year  may  be  followed  in  the  same  way.  The  first  of  the  two 
figures  placed  above  each  tooth  represents  a  date  at  which  the  apex  of  the  root  of 
that  tooth  has  frequently  been  found  sufficiently  narrowed  to  permit  of  root  filling. 
The  second  figure  represents  the  date  at  which  tho  apex  of  the  root  is  occasionally 
found  too  widely  open  for  root  filling.  Even  wider  variations  will  sometimes  be 
found.  It  must  be  remembered  that  in  such  a  diagrammatic  representation,  only  an 
approximation  to  a  general  average  can  be  expect<'d.  Tolerably  wide  variations  will 
occur. 


TREATMENT    OF    THE    DENTAL    PULP.  295 

desired  for  appearance,  a  gutta-percha  sealing  may  be  placed 
within  the  cavity,  without  entirely  filling  it,  and  it  may  then  be 
covered  with  cement  or  temporary  stopping. 

Rationale  of  pulp  and  root  canal  medication. 

Aside  from  the  measures  which  may  be  taken  to  prevent 
diseases  of  the  pulp,  there  is  little  that  may  be  done  in  treatment 
which  does  not  involve  the  removal  of  the  pulp  and  the  filling  of 
the  root  canals.  Therefore,  except  in  cases  of  hyperemia,  treat- 
ment is  generally  not  undertaken  with  the  idea  of  saving  the 
pulp.  In  operations  for  pulp  removal  and  root  filling,  we  should 
have  several  things  prominently  in  mind:  (1)  To  avoid  pain  as 
much  as  is  possible;  (2)  to  maintain  strict  asepsis-;  (3)  to  avoid 
injury  to  the  tissues  about  the  apex  of  the  root  either  by  infec- 
tion through  the  root  canal  or  by  the  medicines  used. 

If  the  pulp  is  vital,  the  patient  may  present  complaining  of 
pain.  This  may  be  caused  by  pressure  within  the  pulp  chamber ; 
or  by  an  inflammation  of  the  pulp  tissue  without  pressure,  the 
pulp  chamber  being  exposed  by  a  cavity  in  the  tooth.  In  the 
former  case  the  opening  of  the  pulp  chamber  will  relieve  the 
congestion  and  reduce  the  pain,  and  the  operations  for  the 
destruction  and  removal  of  the  pulp  may  be  undertaken  at  once. 
If  the  pain  is  caused  principally  by  inflammation  of  the  pulp,  a 
medicament  is  indicated  to  reduce  the  inflammation,  and  in  m.y 
hands  nothing  has  proven  more  satisfactory  than  oil  of  cloves 
or  the  "1-2-3"*  preparation  for  this  purpose.  It  is  also  impor- 
tant to  protect  such  a  pulp  from  thermal  shock  and  it  should  at 
the  same  time  be  protected  against  infection.  Therefore,  the 
medicament  should  be  sealed  in,  and  should  usually  remain  for  a 
week. 

When  a  pulp  has  been  removed,  the  indication  is  for  a  med- 
icament which  will  keep  the  root  canal  sterile.  For  this  purpose 
any  mild  antiseptic  may  be  used.  In  sealing  medicaments  in 
root  canals,  it  should  always  be  kept  in  mind  that  the  drug  may 
penetrate  the  apical  foramen  and  come  in  contact  with  the  tissues 
about  the  apex  of  the  root.  The  rule  should  be  that  no  drug 
which  would  seriously  injure  the  soft  tissues,  if  held  in  contact 
with  them,  should  be  sealed  in  a  root  canal.  Therefore,  such 
drugs  as  95  per  cent  phenol,  oil  of  cassia,  or  preparations  con- 

*  One  part  oil  of  cassia,  two  parts  of  phenol,  throe  parts  oil  of  gaultlioria.  The 
oils  should  be  mixed,  and  melted  crystals  of  phenol  should  be  added.  This  makes  :i 
clear  solution.  If  95  per  cent  phenol  be  added,  it  will  make  a  cloudy  solution.  1 
have  not  personally  been  responsible  for  the  term  "  1-2-3,"  which  has  become  a 
common  term,  but  T  have  accepted  it  and  mentioned  it  often  in  what  I  have  written. 


296  SPECIAL    DENTAL   PATHOLOGY. 

taining  formalin  which  will  injure  the  tissues,  should  never  be 
sealed  in  root  canals.  Certainly  no  drug  should  be  sealed  in 
a  root  canal,  which  would  cause  serious  injury  to  soft  tissue 
elsewhere,  as  the  skin,  when  held  in  contact  with  it.  The  use  of 
such  drugs  has,  doubtless,  so  injured  the  apical  tissues  as  to  lead 
to  the  foraiation  of  a  fair  percentage  of  incurable  chronic  alveo- 
lar abscesses. 

Experiments  with  medicaments  used  in  pulp  treatment. 
During  the  winter  of  1897-98,  Dr.  A.  H.  Peck,  who  was  at  the 
time  associated  with  me  as  a  teacher  in  Northwestern  University 
Dental  School,  conducted  an  extended  series  of  experiments 
to  determine  both  the  antiseptic  and  irritating  properties  of 
various  drugs  used  in  root  canal  medication.  Among  other 
things,  Dr.  Peck  took  pellets  of  cotton  saturated  with  these  drugs 
and  sealed  them  to  the  skin  of  guinea  pigs,  and  to  the  skin  of  his 
own  person  as  well,  under  rubber  cups,  for  varying  lengths  of 
time.  These  experiments,  which  were  reported  to  the  Illinois 
State  Dental  Society,*  proved  very  conclusively  that  many  of 
the  drugs  then  in  use  were  not  only  poisonous  to  the  vegetable 
cell,  but  to  animal  cells  as  well.  Such  drugs  are  not  indicated  in 
root  canals. 

I  quote  part  of  Dr.  Peck's  report  on  oil  of  cassia,  and  make 
brief  reference  to  his  statements  regarding  several  other  drugs : 

"As  a  test  of  the  irritating  properties  of  oil  of  cassia,  a 
pellet  of  cotton  was  saturated  with  it  and  placed  in  a  small 
rubber  cup,  to  prevent  evaporation.  This  was  applied  to  the 
surface  of  the  skin  and  held  there  by  means  of  a  piece  of  court- 
plaster  large  enough  to  cover  it  over  and  stick  tightly  to  the 
surface  of  the  skin  about  the  edges.  This  was  retained  in  place 
for  twenty-four  hours,  during  which  time  the  irritation  to  the 
soft  parts  was  by  no  means  a  pleasant  feature.  At  the  end  of 
this  period  a  blister  invariably  forms ;  however,  the  inflamma- 
tion in  the  tissues  at  this  time  is  not  very  great.  The  blister  will 
occupy  an  area  from  one-half  to  one-third  greater  than  that  to 
which  the  oil  is  directly  applied,  and  will  fill  and  refill  with  serum 
several  times  before  any  tendency  to  recovery  is  noticed.  At  the 
end  of  forty-eight  hours  the  inflammation  in  the  parts  involved 
is  intense,  and  occupies  an  area  four  or  five  times  as  great  as 
that  to  which  the  oil  is  directly  applied.  Numerous  small,  inde- 
pendent blisters  almost  invariably  form  about  the  circumference 

*  The  Essential  Oils  and  Some  Other  Agents,  Their  Antiseptic  Value,  also  Their 
Irritating  or  Nonirritating  Properties.  By  A.  H.  Peck,  Transactions  Illinois  State 
Dental  Society,  1898,  p.  154;    Dental  Review,  Vol.  XI,  1898,  p.  593. 


TREATMENT    OF    THE    DENTAL    PULP.  297 

of  the  inflamed  area.  This  condition  continues  for  several  days, 
and  while  the  inflammatory  process  is  at  its  height  the  sore  is 
one  of  the  ugliest  and  most  formidable  in  appearance  it  has  ever 
been  my  privilege  to  look  upon.  These  sores,  also,  are  very  slow 
in  healing. 

"To  my  mind,  it  is  clearly  proven  that  while  the  antiseptic 
and  germicidal  properties  of  this  oil  are  of  the  highest  order,  it 
is  one  of  the  most  irritating,  in  its  effects  on  the  soft  tissue,  of 
all  the  agents  with  which  we  have  anything  to  do.  And  because 
of  these  effects,  as  outlined  above,  I  feel  perfectly  justified  in 
making  the  statement  that  oil  of  cassia  should  never  be  used  as 
a  dressing  in  the  root  canals  of  teeth. ' ' 

Oil  of  cinnamon,  beechwood  creosote,  oil  of  cloves,  "1-2-3," 
formalin,  and  several  other  medicaments  were  experimented 
with  in  the  same  way  and  the  results  stated.  Oil  of  cinnamon 
was  reported  as  causing  "considerable  irritation"  but  not  so 
much  as  oil  of  cassia.*  The  application  of  beechwood  creosote 
was  "practically  nonirritating. "  Oil  of  cloves  was  reported  as 
"absolutely  nonirritating.  An  application  to  the  surface  of 
the  skin  for  thirty-six  hours  left  no  more  evidence  of  having 
been  confined  there  than  so  much  sterilized  water  would  have 
done."  The  application  of  "1-2-3"  produced  "a  slight  sear- 
ing." Formalin  was  used  full  strength  ("saturated  solution  of 
the  gas  formaldehyde  in  water")  which  was  at  that  time  recom- 
mended for  the  treatment  of  root  canals.  It  produced  a  very 
severe  inflammation,  causing  marked  systemic  disturbances,  and 
destroyed  a  large  mass  of  tissue. 

Recently,  at  my  request,  Dr.  E.  S.  Willard,  professor  of 
bacteriology  in  Northwestern  University  Dental  School,  made  a 
similar  series  of  experiments,  sealing  three  drops  of  each  med- 
icament for  twenty-four  hours  on  the  forearms  of  members  of 
the  senior  class,  who  volunteered  for  the  purpose.  Direct  color 
photographs  of  six  of  the  arms  are  reproduced  in  Figures  347  to 
352,  and  six  other  photographs  are  reproduced  in  black  and 
white  in  Figures  353  to  358.  Wliile  other  applications  were 
made,  those  illustrated  were  selected  as  representing  typical 
results.  Descriptions  of  the  various  cases  are  given  in  connec- 
tion with  the  ilhistrations.  It  is  therefore  only  necessary  to 
add  a  general  statement  here. 

♦During  the  Boxer  war  in  China  it  was  impossible  to  get  oil  of  cassia,  and  sub- 
stitutes were  placed  on  the  market.  I  have  been  unable  to  secure  pmo  oil  of  cassia 
since.     A  special  effort  to  do  so  was  made  recently,  without  success. 


298  SPECIAL    DENTAL   PATHOLOGY. 

The  most  important  differeuce  between  the  results  of  these 
experiments  and  those  made  by  Dr.  Peck  seventeen  years  ago  is 
in  the  inflammation  caused  b)^  oil  of  cassia.  In  the  recent  tests, 
it  seems  to  have  caused  less  inflammation,  yet  far  too  much  to 
permit  of  its  use  in  a  root  canal.  The  difference  is  doubtless 
due  to  the  difference  in  the  purity  of  the  two  specimens.  Oil  of 
cloves  and  beechwood  creosote  each  produced  practically  no 
inflammation,  **  1-2-3"  only  a  slight  irritation,  and  oil  of  cinna- 
mon produced  a  large  blister,  exactly  duplicating  Dr.  Peck's 
results.  Cresol  and  formalin  in  each  instance  in  Dr.  Willard's 
experiments  produced  a  very  deep  inflammation  which  was 
painful,  so  much  so  that  one  student  removed  the  application 
after  seven  hours.  This  arm  showed  a  scar  six  weeks  later 
which  looked  as  though  the  area  had  been  burned.  No  blister 
occurred  on  any  of  the  arms  to  which  this  medicament  was 
applied;  the  tissue  turned  a  yellowish  color  as  though  it  would 
slough  away.  Figure  358  shows  one  arm  photographed  on  the 
seventh  day  after  the  removal  of  the  drug.  Three  pins  are 
shown  sticking  into  the  arm.  One  of  these  was  pushed  directly 
in  8  mm.  (about  1-3  of  an  inch)  before  any  sensation  was  felt. 
Two  months  after  the  application,  induration  was  yet  present 
and  the  area  still  looked  as  though  some  tissue  would  be  lost. 
A  drug  so  injurious  to  tissue  should  not  be  sealed  in  a  root  canal. 

The  subject  of  the  use  of  antiseptics  in  contact  with  the 
tissues,  in  the  irrigation  of  wounds,  is  discussed  under  a  separate 
heading.  I  have  referred  to  Dr.  Peck's  paper  and  reported  the 
recent  experiments  to  impress  the  fact  that  those  antiseptics 
which  are  least  irritating  to  the  soft  tissues  are  indicated  for 
sealing  in  root  canals,  to  avoid  the  danger  of  serious  injury  to 
the  periapical  tissues  and  the  establishment  of  chronic  alveolar 
abscess.  The  principal  purpose  of  placing  a  medicament  in  the 
canal  is  to  certainly  keep  the  canal  sterile,  to  prevent  hemato- 
genous infection  of  any  portions  of  the  pulp  which  might  remain 
for  the  time. 

Preventive  treatment  of  hyperemia  and  inflammation  of  the 

PULP. 

As  hyperemia  may  terminate  in  inflammation,  the  preven- 
tive treatment  should  be  the  same  for  both.  Such  treatment 
will  also  be  preventive  in  the  highest  degree  against  alveolar 
abscess,  and  its  sequelae. 

In  reviewing  the  various  causes  of  hyperemia  of  the  pulp 
which  have  been  mentioned,  it  will  be  recognized  that  many  cases 


TREATMENT   OF   THE   DENTAL   PULP.  299 

may  be  prevented  by  greater  care  in  dental  operations.  In  the 
preparation  of  cavities  care  should  be  taken  to  avoid  near 
approach  to  the  pulp,  or  in  cavities  which  are  necessarily  deep, 
nonconductors  should  be  placed  to  avoid  the  danger  of  a  hypere- 
mia. In  those  cavities  in  which  two  or  more  walls  are  even  fairly 
close  to  the  pulp,  as  in  mesio-disto-occlusal  cavities,  it  is  well  to 
use  a  nonconductor  under  the  filling.  Every  precaution  should 
be  taken  to  avoid  the  creation  of  heat  or  undue  pulp  irritation  iu 
all  operating.  Attention  has  already  been  called  to  the  danger 
in  the  use  of  disks,  stones,  etc. 

Thorough  and  frequent  examinations.  Involvement  of 
the  pulp  by  caries  may  be  prevented  in  proportion  as  we  find 
and  fill  cavities  before  they  become  deep.  We  should,  then,  be 
very  thorough  in  examinations  of  the  mouth,  to  find  cavities 
while  they  are  small.  We  should  request  patients  to  come  in  at 
stated  intervals  for  examination,  in  order  that  cavities  may  be 
discovered  before  the  dentin  has  been  deeply  penetrated. 
Patients  should  be  brought  to  realize  the  advantage  of  such  a 
plan. 

Avoid  near  approach  and  exposure  of  pulp  in  cavity  prepa- 
ration. In  cavity  preparation,  the  utmost  care  should  be  taken, 
not  only  to  avoid  exposing  the  pulp,  but  to  avoid  near  approach 
to  the  pulp  chamber,  or  to  the  recessional  lines  of  the  pulpal 
horns.  The  dentin  grows  from  the  dento-enamel  junction 
inward,  and  the  pulp  recedes  and  becomes  smaller  as  the  dentin 
is  formed.  The  lines  along  which  the  horns  of  the  pulp  recede 
as  the  dentin  is  gradually  formed  are  called  the  recessional  lines 
of  the  pulpal  horns.  Oftentimes  a  horn  of  a  pulp  will  persist 
as  a  slender  thread  of  pulp  tissue  reaching  far  toward  the  dento- 
enamel  junction,  even  when  the  pulp  chamber  has  become  quite 
small.  A  very  large  percentage  of  the  accidental  exposures  of 
the  pulp  in  cavity  preparation  are  exposures  of  the  horns  of  the 
pulp.  Therefore,  it  is  especially  important  that  these  lines  be 
avoided  in  preparing  cavities.  In  the  bicuspids  and  molars, 
there  is  a  recessional  line  for  each  cusp.  This  line  is  in  the 
direction  of  a  line  drawn  from  the  point  of  each  cusp  toward  the 
corresponding  angle  or  horn  of  the  pulp  chamber.  (See 
Figure  359.) 

A  pulp  is  in  danger  of  death  from  thermal  shock  subsequent 
to  the  placing  of  a  filling,  if  the  cavity  be  cut  deeply  enough  to 
closely  approach  the  pulp  chamber  or  horns  of  the  pulp  at  any 
single  point,  or  if  much  of  the  cavity  be  cut  only  fairly  deep. 
In  other  words,  a  pulp  might  die  from  thermal  shock  from  a 


300  SPECIAL    DENTAL   PATHOLOGY. 

metal  filling  placed  in  a  small  deep  cavity,  or  from  a  very  broad, 
but  comparatively  shallow  cavity.  There  would  be  much  more 
danger  of  thermal  shock  from  a  mesio-disto-occlusal  filling  of 
moderate  depth  than  from  a  simple  occlusal  filling  of  the  same 
depth,  because  the  mesio-disto-occlusal  filling  would  be  in  con- 
tact with  the  dentinal  tubules  on  three  sides  of  the  pulp  and 
sudden  changes  of  temperature  would  produce  greater  shock. 
A  careful  review  of  the  cavity  forms  in  my  work  on  Operative 
Dentistry  will  show  that  they  are  x)lanned  to  give  the  best  pos- 
sible resistance  and  retention  forms,  and  at  the  same  time  avoid 
near  approach  to  the  pulp  chamber  and  the  recessional  lines  of 
l)ulpal  horns.  Naturally,  no  cavity  should  be  cut  deeper  in  the 
dentin  than  is  required  for  retention. 

Use  of  nonconductors.  In  every  case  in  which  it  is  neces- 
sary, either  in  the  removal  of  caries,  or  in  securing  proper  cavity 
form,  to  cut  deeply  enough  to  endanger  the  life  of  the  pulp  from 
thermal  shock,  a  nonconductor  should  be  placed  beneath  the 
filling.  The  technic  of  placing  nonconductors  is  very  simple. 
In  some  cases,  particularly  to  cover  axial  walls  of  incisor  proxi- 
mal cavities,  a  piece  of  quill,  cut  from  a  quill  toothpick,  may  be 
used.  This  is  cut  to  lie  against  the  axial  wall  and  is  held  in 
place  until  one  or  two  pieces  of  gold  have  been  condensed,  over- 
lapping a  margin  of  the  quill.  A  thin  layer  of  oxyphosphate  of 
zinc  cement  may  be  generally  used  as  a  nonconductor.  This 
may  be  conveniently  placed  by  cutting  a  piece  of  stiff  writing- 
paper  to  fit  the  cavity,  and  after  putting  the  necessary  amount 
of  cement  on  this,  it  should  be  carried  to  the  cavity  with  the 
cement  next  to  the  dentin  wall  to  be  covered,  and  gentle  pressure 
made  on  the  paper  until  the  cement  is  spread  out  into  a  thin 
layer. 

Treatment  of  hyperemia. 

In  cases  in  which  there  is  evidence  of  hyperemia  which  has 
developed  as  a  result  of  excessive  changes  of  temperature,  the 
patient  should  be  urged  to  use  the  greatest  care  to  avoid  hot  or 
cold  drinks,  hot  or  cold  food,  or  breathing  cold  air  through  the 
mouth.  If  these  are  rigorously  avoided  for  a  few  days,  the 
milder  hyperemias  will  disappear  as  the  rule.  If  the  patient  is 
one  who  must  be  out  of  doors  in  cold  weather,  the  sensitive  teeth 
may  be  protected  by  a  covering  of  gutta-percha  or  modeling  com- 
pound, molded  to  fit  closely,  but  which  may  be  removed  and 
replaced  by  tlie  patient  at  meal  time.  Some  patients  will  make 
use  of  such  an  appliance,  others  will  be  so  much  irritated  by  it, 


TREATMENT    OF    THE    DENTAL    PULP.  301 

that  they  will  not  keep  it  in  the  mouth.  In  some  cases  the  exposed 
portion  of  the  tooth  may  be  partially  or  entirely  covered  with 
cement.  If  it  happens  to  be  a  molar  tooth,  copper  cement  may 
be  used,  and  it  should  be  placed  on  the  occlusal  surfaces  of  the 
other  molars  of  the  same  arch  on  both  sides  to  relieve  the  occlu- 
sion on  the  hyperemic  tooth.  If  these  precautions  are  not  taken, 
the  condition  is  likely  to  grow  progressively  worse.  The  par- 
oxysms of  pain  will  become  more  frequent,  they  will  be  excited 
by  a  less  degree  of  temperature  change,  and  the  duration  of  the 
paroxysms  will  gradually  increase.     Finally  the  pulp  will  die. 

I  have  seen  cases  in  which  the  tooth  was  so  sensitive  to 
temperature  changes  that  water  three  degrees  off  the  tempera- 
ture of  the  body,  either  too  hot  or  too  cold,  would  excite  a  severe 
paroxysm  of  pain.  Even  these  cases  will  get  well,  as  the  rule, 
if  the  utmost  care  is  exercised  to  avoid  temperature  changes 
which  produce  pain.  If  paroxysms  can  be  avoided  by  keeping 
the  tooth  at  even  temperature  of  the  body,  there  is  a  good  oppor- 
tunity for  recovery. 

The  difficulty  in  the  treatment  of  hyperemia  is  in  the  control 
of  the  patient,  or  in  bringing  the  patient  to  a  realization  of  the 
cause  of  the  condition  and  of  the  treatment  necessary  to  allow 
the  pulp  to  recover.  We  have  some  peculiar  examples  of  this. 
Many  patients  with  hyperemic  teeth  have  told  me  that  the  par- 
oxysms of  pain  were  never  produced  by  hot  or  cold  taken  into  the 
mouth,  yet  a  dash  of  cold  water  or  a  bit  of  warm  gutta-percha 
applied  to  the  tooth  would  produce  a  paroxysm  of  pain.  Some 
patients  can  not  be  induced  to  take  any  care  whatever  to  prevent 
thermal  shock  until  the  pulp  has  an  opportunity  to  recover. 

When  a  patient  presents  with  a  hyperemic  tooth,  it  is  a  good 
rule  for  the  dentist  to  emphasize  the  fact  that  one  of  two  things 
will  probably  occur ;  either  the  pulp  will  very  gradually  recover, 
or  the  paroxysms  may  become  worse  and  then  the  tooth  may 
rather  suddenly  be  entirely  free  from  pain.  The  patient  should 
be  warned  that  if  the  latter  occurs,  the  probability  is  that  the 
pulp  has  died,  and  there  is  the  danger  that  an  abscess  will 
develop  unless  the  dead  pulp  is  promptly  removed.  In  any 
event  the  dentist  should,  if  possible,  have  the  patient  return  at 
stated  intervals,  in  order  that  he  may  have  definite  knowledge  of 
the  progress  of  the  case. 

Capping  exposures  of  the  dental  pulp. 

In  discussing  the  healing  powers  of  the  dental  pulp,  I  gave 
a  historical  review  of  the  efforts  whicli  have  been  made  to  save 

as 


302  SPECIAL   DENTAL   PATHOLOGY. 

exposed  pulps  by  capping,  in  which  it  was  pointed  out  that  inost 
such  attempts  resulted  disastrously,  and  the  operation  should  not 
be  undertaken  except  under  the  most  favorable  conditions. 

In  cases  in  which  there  occurs  in  the  preparation  of  a  cavity 
slight  exposure  of  a  previously  uninflamed  pulp  in  the  mouth  of 
a  young  person,  the  effort  should  often  be  made  to  save  such  a 
pulp  by  capping.  This  is  especially  important  if  the  age  of  the 
patient  is  such  that  there  might  be  some  question  as  to  complete 
calcification  of  the  root.  While,  as  a  rule,  it  would  be  expected 
that  the  pulp  would  die,  there  remains  the  possibility  that  it  may 
live  to  complete  the  formation  of  the  root.  Whenever  a  capping 
is  undertaken  under  these  conditions,  a  temporary  filling  should 
be  placed  in  the  cavity  and  the  vitality  of  the  pulp  tested  at 
stated  intervals,  so  that  the  pulp  may  be  promptly  removed  if  it 
dies.  If,  upon  the  removal  of  the  pulp,  it  should  be  found  that 
the  apical  foramen  is  so  large  that  it  is  impossible  to  make  a 
proper  root  filling,  the  only  alternative  is  to  extract  the  tooth. 

It  became  my  habit  of  practice  at  quite  an  early  date,  to 
make  a  capping  in  cases  occurring  in  the  teeth  of  children  where 
the  prospect  seemed  favorable  and,  if  this  failed,  either  to 
remove  the  pulps  or  to  extract  the  teeth.  I  should  advise 
strongly  that  in  such  cases  we  should  abandon  the  case  at  once 
if  the  first  capping,  which  seemed  to  have  been  judiciously  made, 
fails.  Every  renewed  attack  of  pain  marks  an  extension  of  the 
inflammation  in  such  cases.  The  first  effort  has,  therefore,  been 
made  under  the  very  best  conditions  which  could  occur  in  the 
particular  case.  A  repetition  of  the  effort  is  simply  to  worry 
the  child  without  accomplishing  anything  in  such  a  large  pro- 
portion of  the  cases  that  it  is  not  justifiable. 

The  operation  of  capping  should  be  generally  employed  in 
cases  in  which  a  slight  exposure  has  occurred  during  the  child- 
hood period  of  the  pennauent  teeth,*  even  though  this  exposure 
has  been  made  by  caries.  During  this  period  the  apical  end  of 
the  partially  formed  root  is  wide  open,  so  that  there  is  little 
danger  of  the  death  of  the  pulp  from  strangulation.  There  is 
room  for  both  arteries  and  veins  to  become  enlarged.  (See 
Figures  360,  361  and  362.)  Such  pulps,  if  exposed  by  caries, 
will  generally  die;  although  a  few  live.  If  slightly  exposed  in 
excavating,  a  considerable  number  will  live  if  carefully  capped 
and  protected  from  further  irritation. 

*  For  each  tooth,  the  period  between  the  time  of  its  eruption  and  the  complete 
calcification  of  the  root  is  the  childhood  period.     (See  Fig.  363.) 


treatment  of  the  dental  pulp.  303 

Time  of  complete  calcification  of  the  roots  of  the  various 
TEETH.  I  reproduce  herewith  an  illustration  from  my  work  on 
Operative  Dentistry,  showing  the  average  time  of  the  sufficient 
narrowing  of  the  apical  foramen  for  root  filling  in  the  various 
teeth,  with  something  of  the  variations  which  occur  in  this 
process.  (See  Figure  363.)  Cases  will  be  found,  however,  in 
which  the  roots  of  teeth  should  not  be  filled  so  early  as  the  ages 
mentioned,  and  this  should  always  be  determined  by  examination 
of  the  individual  case.  It  is  the  habit  of  many  dentists  to 
attempt  to  fill  the  roots  of  teeth  of  children  at  too  early  an  age, 
and  hence  disastrous  results  occur. 

The  examinations  for  determining  the  time  of  the  narrowing 
of  the  apical  foramen  sufficiently  for  root  filling,  have  been  car- 
ried out  by  actual  measurements  in  cases  in  which  I  have  pre- 
pared to  fill  the  roots  and  have  found  the  apical  foramen  still  too 
broad,  or  even  funnel-shaped,  necessitating  the  extraction  of  the 
teeth;  also  by  the  examination  of  the  width  of  the  apical  fora- 
men in  a  large  number  of  teeth  extracted  for  children,  noting 
their  ages  in  both  these  conditions,  and  making  records  of  them ; 
also  by  radiographs  taken  especially  for  this  purpose.  Dr.  C.  F. 
B.  Stowell  reported  in  the  Northwestern  Dental  Journal,  Vol. 
Vni,  p.  57,  a  tabulation  of  measurements  of  the  foramina  of 
4378  teeth  extracted  during  root  development.  The  measure- 
ments are  practically  the  same  as  my  own. 

Indications  for  capping.  The  indications  for  capping  may 
be  summed  up  as  follows:  (1)  During  the  childhood  period 
(previous  to  the  time  of  complete  formation  of  root)  while  apical 
foramen  is  large,  whether  exposure  is  by  caries  or  in  excavating ; 

(2)  slight  exposures  with  hand  excavator  in  fully  formed  teeth; 

(3)  never  in  fully  formed  teeth  if  exposed  by  caries;    (4)  never 
if  exposure  is  made  by  a  bur. 

Technic  of  capping.  If  the  effort  is  to  be  made  to  save  an 
exposed  pulp,  the  aim  should  be  to  avoid  as  much  as  possible 
any  further  irritation.  If  there  be  any  hemorrhage,  the  1)1  ood 
should  be  absorbed  with  cotton.  The  immediate  area  should 
then  be  slightly  moistened  with  a  very  mild  antiseptic,  such  as 
oil  of  cloves  or  ' '  1-2-3. ' '  A  strong  antiseptic  should  not  be  used, 
on  account  of  the  danger  of  increasing  the  inflammation  of  the 
pulp.  The  dentin  about  the  exposure  should  be  dried  with  cot- 
ton. Then,  if  the  shape  of  the  cavity  will  permit,  a  very  thin 
wafer  of  pink  base-plate  gutta-percha,  slightly  moistened  with 
eucalyptol,  should  be  placed  over  the  exposure.  The  oucalyptol 
will  render  the  gutta-percha  sufficiently  sticky,  so  that  it  will 


304  SPECIAL   DENTAL.   PATHOLOGY. 

adhere  to  the  dentin.  Then  a  small  piece  of  stiff  writing-paper 
should  be  cut  so  that  it  may  be  laid  in  the  cavity  over  the  gutta- 
percha. When  this  is  ready,  a  mixture  of  oxyphosphate  of  zinc 
cement  should  be  made  and  a  small  globule  placed  on  the  piece 
of  paper.  The  paper  should  then  be  carried  to  the  cavity  and 
placed  with  the  cement  side  over  the  gutta-percha,  making  gentle 
pressure  on  the  paper  to  flatten  the  cement  into  a  thin  layer. 
If  the  cavity  is  too  small  to  permit  the  use  of  the  wafer  of  gutta- 
percha, this  may  be  omitted  and  the  capping  made  by  placing  the 
cement  directly  over  the  exposure,  using  veiy  gentle  pressure  to 
avoid  forcing  the  cement  into  the  pulp  chamber. 

After  the  cement  is  thoroughly  hard,  a  temporary  filling 
should  be  placed,  leaving  the  paper  over  the  cement  capping  in 
order  that  there  will  be  no  danger  of  removing  the  capping  when 
the  temporary  filling  is  removed.  In  all  such  cases,  tests  should 
be  made  at  frequent  intervals  to  know  the  condition  of  the  pulp. 
Permanent  fillings  should  usually  be  postponed  until  the  forma- 
tion of  the  root  is  certainly  completed,  or  for  six  months  or  more 
in  cases  in  which  cappings  have  been  made  in  adult  teeth. 

Treatment  of  Vital  Dental  Pulps. 

Exposure  of  the  dental  pulp. 

Conditions  presenting.  The  pulp  of  a  tooth  (1)  may  be 
found  exposed  by  caries  so  that  it  lies  naked  and  in  view;  (2) 
it  may  have  been  reached  by  the  extension  of  caries  but  remain 
covered  by  a  softened  carious  mass  of  dentin ;  (3)  it  may  become 
exposed  by  accident  during  the  preparation  of  a  carious  cavity. 

The  first  and  second  cases  are  so  similar  that  they  may  be 
considered  together,  only  noticing  differences  of  manipulation 
as  they  occur.  In  both,  the  supposition  is  that  the  pulp  is  to  be 
destroyed  and  removed.  In  the  first  procedure,  the  problem  is 
the  preparation  of  the  cavity  for  the  treatment  of  the  exposed 
pulp,  with  the  least  pain  and  inconvenience  to  the  patient. 

Opening  the  cavity.  The  requirement  is  that  the  cavity  be 
opened  by  the  removal  of  all  overhanging  enamel  and  that  the 
surrounding  walls  be  freed  from  carious  material,  perfectly 
cleaned  to  solid  dentin  and  cut  to  a  form  that  will  certainly 
retain  a  temporary  filling  for  the  purpose  of  sealing  in  applica- 
tions that  may  be  required  in  the  treatment.  It  is  not  required 
here  that  the  cavity  be  cut  to  the  full  outline  form,  as  it  will  be 
prepared  to  receive  the  permanent  filling  later,  nor  that  the  per- 
manent anchorages  be  provided ;  but  it  is  required  that  good  and 


TREATMENT    OF    THE    DENTAL    PULP.  305 

sufficient  anchorage  be  made  for  a  temporaiy  gutta-percha  filling 
against  good,  clean  surrounding  walls  in  every  part.  The  cavity 
should  be  opened  sufficiently  wide  to  admit  of  the  free  and  easy 
application  of  instruments  for  the  exposure  of  the  pulp.  In 
doing  this,  especial  care  should  be  taken  that  the  excavators  be 
not  directed  toward  the  pulp  of  the  tooth  and  that  it  be  not  inter- 
fered with  in  any  way  until  after  the  surrounding  walls  are 
clean  and  solid.  This  excavation  should  be  done  upon  the  prin- 
ciples laid  down  for  the  excavation  of  cavities  in  the  class  to 
which  the  case  in  hand  belongs. 

RuBBEE  DAM  ON.  It  must  be  understood  that  the  pulp  is  not 
to  be  exposed  or  the  pulp  chamber  entered  at  any  time,  either 
primarily  or  secondarily,  without  the  protection  of  the  rubber 
dam.  If  the  rubber  dam  has  not  been  placed  at  the  beginning, 
it  should  be  placed  after  the  cavity  is  well  opened,  and  every 
preparation  should  be  made  for  the  best  possible  view  of  the 
deeper  parts  of  the  cavity,  and  the  field  of  operation  sterilized. 
The  carious  material  should  then  be  removed  from  the  deeper 
parts  of  the  cavity,  and  from  about  the  exposure.  In  case  the 
exposure  is  large  and  the  pulp  is  already  laid  bare,  the  excavat- 
ing need  not  be  very  perfectly  done  at  first,  the  necessity  being 
that  applications  can  be  laid  directly  upon  the  pulp  tissue  and 
perfectly  sealed  in  place  by  a  temporary  filling.  It  must  be 
done,  however,  before  any  part  of  the  pulp  is  removed  in  order 
to  be  sure  that  no  infectious  material  be  carried  from  the  cavity 
into  the  root  canals. 

Make  exposure  with  broad  instrument.  In  case  the  pulp 
is  covered  with  carious  material  only,  this  should  be  removed 
and  the  tissue  of  the  pulp  laid  bare.  In  every  case  this  should 
be  done  with  the  broadest  cutting  instrument  that  is  applicable 
to  the  position,  usually  with  the  spoons.  One  should  never 
undertake  to  remove  softened  material  from  over  a  pulp  with  an 
instrument  so  small  that  it  is  liable  to  pass  through  the  opening 
into  the  pulp  chamber,  lacerate  the  pulp  tissue,  and  inflict 
unnecessary  pain.  This  should  be  taken  as  a  principle  con- 
trolling every  procedure  in  this  class  of  cases,  and  the  operator 
should  see  to  it  particularly  that  the  cavity  be  so  opened  and 
prepared  that  broad  points  may  be  used  with  facility. 

In  bicuspids  and  molars.  When  these  preparations  have 
been  made,  the  best  direction  in  which  to  make  a  sweeping  cut 
having  been  determined,  a  spoon  should  bo  placed  with  its  edge 
under  the  carious  mass  close  against  one  of  tlie  walls  of  the 


306  SPECIAL   DENTAL   PATHOLOGY. 

cavitj^  and  with  a  strong  thrust  in  a  curved  direction  it  should 
be  carried  across  to  the  other  side,  cutting  at  once  to  the  full 
depth  of  the  softened  dentin.  If  possible,  the  whole  mass  should 
be  removed  at  a  single  cut,  laying  the  pulp  bare.  The  position 
of  the  spoon  for  making  such  a  cut  is  shown  in  Figure  364.  This 
should  be  carefully  planned  and  firmly  executed.  If  the  cut 
should  be  through  the  supei^cial  portions  of  the  pulp,  excising 
a  portion  of  the  tissue,  it  is  just  as  well,  for  when  the  hemor- 
rhage has  ceased,  we  are  sure  of  the  best  condition  for  the  absori3- 
tion  of  remedies  for  destroying  it,  whether  this  be  done  by  the 
application  of  arsenic  or  by  use  of  cocain  under  pressure.  In 
some  broad  cavities  in  which  it  may  seem  that  the  carious  mass 
is  too  broad  to  be  removed  at  a  single  cut,  one  or  more  prepara- 
tory cuts  may  be  made  to  either  side,  avoiding  the  pulp,  before 
making  the  principal  cut  for  its  exposure.  An  exposure  of  tlie 
pulp  made  in  this  way  is  usually  not  very  painful,  and,  even  if 
it  be  very  sensitive,  the  duration  of  the  pain  is  reduced  to  the 
shortest  limit  of  time. 

In  PROXIMAL  CAVITIES  IN  INCISORS.  In  proximal  cavities  in 
the  incisors,  the  spoons  20-9-12*  generally  can  not  be  used  for 
want  of  room.  Much  oftener  the  spoons  15-8-12  or  the  discoid 
are  applicable.  In  these  cavities  the  most  desirable  direction 
for  the  final  cut  for  exposing  the  pulp  is  from  the  gingival 
toward  the  incisal,  directly  over  the  pulp.  In  these  cases  the 
opening  into  the  pulp  is  apt  to  be  long  gingivo-incisally,  and  if 
the  broad  cutting  edge  can  be  placed  at  right  angles  to  this,  it 
is  much  safer  against  dropping  into  the  pulp  chamber  and  pro- 
ducing unnecessary  laceration  of  the  sensitive  tissues.  By  pro- 
ceeding carefully,  this  position,  or  an  angle  closely  proximating 
it,  can  often  be  obtained,  and  then  the  exposure  is  made  with 
safety.  A  discoid  is  really  the  best  instrument  for  the  purpose 
in  this  position.  The  exposure  may  be  made  with  spoons 
10-6-12,  but  with  more  danger  of  inflicting  pain. 

Medication  to  reduce  inflammation.  If  the  patient  has 
suffered  pain,  indicating  considerable  inflammation  of  the  pulp, 
it  will  generally  be  best,  after  making  the  exposure  and  having 
produced  a  slight  hemorrhage,  to  seal  in  a  dressing  of  oil  of 
cloves  for  a  week  to  allow  time  for  the  inflammation  to  subside, 
l)efore  proceeding  with  the  destruction  of  the  pulp.  If  a  pulp 
is  very  much  inflamed,  applications  of  cocain  may  be  extremely 
painful,  without  ])roducing  anesthesia,  and  arsenic  may  cause 

*  For  explanation  of  instrnment  formulsp,  see  Operative  Dentistry,  Vol.  IT. 


TREATMENT    OF    THE   DENTAL   PULP.  307 

the  tooth  to  ache  severely.  By  delaying,  this  pain  may  be 
avoided. 

When  pain  is  uncontrollable.  In  a  limited  nmiiber  of 
cases,  in  which  the  pain  is  severe  and  can  not  be  controlled,  the 
only  possible  procedure  will  be  to  remove  the  pulp  at  once,  or 
to  at  least  lacerate  the  pulp  tissue  sufficiently  to  produce  a  free 
hemorrhage.  To  do  this  without  an  anesthetic  will  cause  excru- 
ciating pain  for  an  instant,  but  relief  will  follow  almost  immedi- 
ately. If  it  be  a  molar  tooth,  a  sufficient  opening  should  be  made 
to  permit  a  spoon  to  be  carried  into  and  swept  around  the  pulp 
chamber;  in  other  teeth,  good  access  having  been  secured,  a 
broach  may  be  thrust  into  the  canal,  withdrawn  a  little  to  be  sure 
that  it  is  free,  then  twisted  several  times  to  engage  the  pulp  and 
remove  it. 

In  these  severe  cases  the  area  of  the  tooth  may  be  anesthe- 
tized with  novocain,  injecting  the  bone  about  the  apex,  or  inject- 
ing the  solution  into  the  nerve  trunk  which  supplies  the  area. 
After  waiting  several  minutes  for  the  effect  of  the  novocain,  the 
rubber  dam  may  be  placed,  and  the  canals  thoroughly  cleansed. 

Destroying  the  dental  pulp  with  arsenic. 

When  the  pulp  has  been  fully  exposed,  the  cavity  should  be 
ready  for  the  application  to  the  pulp  without  further  prepara- 
tion. If  it  is  to  be  destroyed  by  arsenic,  a  piece  of  heavy  writing- 
paper  or  cardboard  should  be  cut  of  such  size  and  form  that  it 
may  be  easily  laid  in  the  cavity  to  cover  the  exposure.  The  walls 
of  the  cavity  should  be  moistened  with  eucalyptol,  or  oil  of  caju- 
put,  to  prepare  them  for  receiving  a  gutta-percha  filling.  Any 
excess  of  oil  should  be  removed.  A  small  amount  of  arsenical 
paste  may  be  placed  upon  the  piece  of  paper  and  applied 
directly  to  the  exposure,  with  the  arsenical  paste  turned  against 
the  pulp.     The  paper  should  be  pressed  gently  to  place. 

Avoi;d  pressure  in  sealing.  A  gutta-percha  filling  should 
be  placed  over  the  paper,  using  especial  care  not  to  make 
unnecessary  pressure  over  the  exposure  of  the  pulp,  as  this 
might  cause  compression  and  pain.  This  gutta-percha  filling 
should  be  as  perfect  in  its  adaptation  to  the  cavity  walls  as  it  is 
possible  to  make  it,  in  order  that  there  may  be  no  leakage  of  the 
arsenic.  Unless  the  cavity  is  so  shallow  that  there  is  lack  of 
room,  a  further  protection  of  the  pulp  against  pressure  may  be 
provided  by  cutting  a  second  piece  of  paper  or  cardboard  and 
fitting  it  over  the  first.  Cement  may  be  mixed  rather  thin  and  a 
globule  placed  over  the  paper,  and  allowed  to  harden,  which  will 


308  SPECIAL   DENTAL   PATHOLOGY. 

give  opportunity  for  the  use  of  any  reasonable  force  in  making 
the  gutta-percha  filling  for  sealing  the  cavity.  In  proximal 
cavities  no  overplus  of  gutta-percha  should  be  allowed  to 
impinge  upon  the  gum  septum  and  cause  absorption,  as  has  been 
mentioned. 

Danger  of  arsenical  poisoning.  Care  should  be  taken  not 
to  use  so  much  of  the  arsenical  paste  that  it  will  run  around  the 
margins  of  the  paper  and  be  in  danger  of  smearing  the  walls  of 
the  cavity,  or  possibly  coming  in  contact  with  the  soft  tissues 
about  the  tooth  and  destroying  them.  This  is  sometimes  a 
serious  accident,  endangering  several  teeth  by  destroying  the 
gum  tissue  and  alveolar  process. 

After  the  temporary  filling  is  completed,  if  there  is  a  possi- 
bility that  any  of  the  arsenical  preparation  may  have  touched 
the  surface  of  the  tooth  or  adjacent  soft  tissues,  these  should  be 
swabbed  with  cotton  saturated  with  dialized  iron,  to  counteract 
the  injurious  effect  of  the  arsenic. 

Subsequent  treatment  if  pulp  only  partly  devitalized. 
Occasionally,  after  the  arsenic  has  remained  in  the  tooth  for 
forty-eight  hours  or  longer,  the  pulp  will  be  found  only  partly 
devitalized.  The  bulbous  portion  may  be  dead  and  that  in  the 
canals  quite  sensitive.  After  removing  the  bulbous  portion,  a 
second  application  may  be  made,  or  if  the  cavity  is  sealed  with  a 
dressing  of  oil  of  cloves  for  a  week,  the  remainder  of  the  pulp 
will  be  found  to  have  died,  as  a  result  of  the  slight  amount  of 
arsenic  which  had  been  absorbed  by  it.  Or,  after  the  removal 
of  the  bulbous  portion,  the  remainder  may  be  anesthetized  with 
cocain  and  removed  at  once. 

Anesthetizing  the  dental  pulp  with  cocain. 

If  it  has  been  decided  to  anesthetize  the  pulp  with  cocain 
under  pressure,  the  opening  into  the  pulp  must  be  free,  and  the 
position  such  that  the  after-manipulation  can  be  readily  done. 
The  surrounding  walls  must  be  sufficient  so  that  the  drug  may  lie 
readily  confined  under  pressure,  and  the  access  should  be  fairly 
direct.     Otherwise  arsenic  should  be  used. 

AATien  the  cavity  has  been  fully  prepared  —  an  occlusal 
cavity  in  an  upper  first  molar,  for  example  —  a  sufficient  amount 
of  cocain  crystals  should  be  dissolved  in  a  drop  of  sterile  water 
(always  made  fresh  for  each  case)  and  a  small  pellet  of  cotton 
saturated  with  this  placed  in  the  cavity  upon  the  exposed  pulp. 
Over  this  should  be  placed  a  pellet  of  soft,  or  unvulcanized  rub- 
ber (used  for  making  vulcanite  plates),  that  will  completely  fill 


TREATMENT    OF    THE    DENTAL    PULP.  309 

the  orifice  of  the  cavity  and  prevent  the  escape  of  the  solution. 
Pressure  should  be  made  upon  this  with  a  broad-faced  amalgam 
plugger.  The  pressure  should  be  gentle  at  first  and  be  gradu- 
ally increased  as  the  pain  subsides,  watching  for  evidence  of 
pain  in  the  countenance  of  the  patient,  until  very  heavy  pressure 
can  be  made.  Then,  if  all  has  gone  well,  the  vulcanizable  rubber 
and  the  cotton  may  be  removed  and  the  pulp  will  be  found 
insensible,  and  its  removal  may  be  proceeded  with. 

Requires  pressure  to  secure  anesthesia.  In  anesthetizing 
the  pulp  in  this  way,  the  cavity  must  be  so  stopped  with  the  soft 
rubber  as  to  prevent  the  escape  of  the  solution  along  the  cavity 
walls,  otherwise,  the  pressure  will  fail  to  force  the  drug  into  the 
pulp  tissue  and  the  anesthesia  will  fail.  This  is  fairly  easy  of 
accomplishment  in  the  cavity  named  above  and  those  of  similar 
form  and  situation.  But  in  proximal  cavities  it  is  often  much 
more  difficult  to  so  place  the  vulcanizable  rubber  that  it  will 
successfully  stop  the  orifice  of  the  cavity.  In  the  molars  and 
bicuspids  this  may  be  done  by  first  placing  a  properly  formed 
piece  of  rubber  against  the  proximating  surface  of  the  adjacent 
tooth  and  then  folding  it  over  the  occlusal  portion  of  the  cavity, 
afterward  applying  pressure  with  a  broad  instrument  point 
selected  to  fit  the  cavity  to  the  best  advantage.  As  one  becomes 
expert  in  tliis,  most  cavities  may  be  so  handled  as  to  successfully 
produce  anesthesia  of  the  pulp. 

When  pulp  is  not  actually  exposed.  In  those  cases  in 
which  the  pulp  is  not  actually  exposed,  so  that  it  is  necessary  to 
cut  through  more  or  less  dentin  to  expose  it,  better  results  will 
usually  be  obtained  in  the  use  of  cocain  anesthesia  by  cutting  a 
small  hole  in  the  dentin,  about  1  mm.  in  diameter,  with  a  bibev- 
eled  drill,  and  placing  a  minute  pledget  of  cotton,  saturated  with 
the  cocain  solution,  in  this  hole.  A  small  piece  of  vulcanizable 
rubber  should  be  applied  over  the  hole  and  pressure  made  with 
an  instrument  that  will  just  fit  in  the  hole.  It  should  be  remem- 
bered that  the  effect  of  the  pressure  applied  will  be  in  inverse 
proportion  to  the  area  of  the  end  of  the  instrument  used,  and 
much  better  penetration  will  be  obtained  with  a  small  instrmnent 
if  the  solution  can  be  confined  in  a  small  hole  so  that  it  will  be 
forced  directly  forward  and  not  spread  laterally,  as  it  would  do 
if  the  small  instruments  were  used  in  a  large  cavity. 

The  best  penetration  of  the  dentin  is  obtained  in  cases  in 
which  the  cocain  solution  is  forced  into  normal  dentinal  tubules. 
For  this  reason,  it  is  often  an  advantage  to  disregard  the  cavity 


310  SPECIAL   DENTAL   PATHOLOGY. 

of  decay  and  drill  into  the  dentin  and  apply  the  cocain  to  normal 
tubules  in  some  other  portion  of  the  crown  of  the  tooth.  For 
example,  in  cases  of  distal  surface  cavities  in  molars,  an  opening 
may  be  made  through  the  occlusal  surface,  in  the  area  which 
must  be  included  in  the  cavity  anyhow,  and  the  cocain  applied  to 
normal  tubules. 

Opening  the  pulp  chambek  pkeparatory  to  removal  of  the 

PULP. 

When  the  pulp  has  been  destroyed  by  arsenic,  the  first  pro- 
cedure, when  the  patient  has  returned  for  the  second  sitting,  is 
to  adjust  the  rubber  dam.  In  proximal  cavities,  in  which  the 
gutta-percha  filling  has  been  placed  firmly  against  the  proxi- 
mating  tooth,  the  filling  should  first  be  cut  through  with  a  fine 
saw,  or  trimmed  away  with  a  sharp  finishing-knife,  in  order  to 
allow  the  rubber  dam  to  pass.  A  single,  quick  cut  with  a  hot 
flat  burnisher  will  accomplish  the  same  result.  "When  the  dam 
is  in  position,  the  field  of  operation  should  be  sterilized  as  has 
been  directed.  The  gutta-percha  filling  may  then  be  softened  by 
wanning  a  burnisher  and  passing  the  end  into  it  and  holding  it 
for  a  moment,  when  the  gutta-percha  may  be  lifted  out.  The 
cavity  should  next  be  freed  from  the  arsenic  paste,  if  it  has  been 
used,  and  washed  out  with  an  antiseptic  and  dried.  The  next 
procedure  is  the  opening  of  the  pulp  chamber. 

In  case  the  pulp  has  been  anesthetized  with  cocain,  the 
rubber  dam  will  be  in  place  and  ready  for  the  opening  of  the 
pulp  chamber,  so  that  from  this  point  the  procedures  in  the  two 
cases  will  be  similar.  In  either  case,  the  pulp  should  first  be 
pricked  cautiously  with  a  very  fine  broach,  to  be  sure  that  it  has 
lost  its  sensibility,  for  sometimes  there  is  a  failure  in  either  way 
of  operating.  It  is  very  bad  practice  to  attempt  to  remove  any 
part  of  the  pulp  tissue  through  a  small  opening.  In  the  bicus- 
pids and  molars,  the  opening  of  the  pulp  chamber  consists  in  the 
removal  of  the  occlusal  portion  or  dentinal  covering  and  the 
manner  of  doing  this  will  depend  much  upon  the  extent  and 
location  of  the  decay. 

Occlusal  cavities  in  molars.  In  the  occlusal  cavities  in  the 
molars  in  which  the  decay  is  large,  often  hoe  6-2-23  can  be  slipped 
into  the  opening,  and,  usijig  it  as  a  hook,  the  entire  roof  of  the 
pulp  chamber  may  be  pulled  away,  uncovering  the  pulp.  But 
when  the  dentinal  covering  is  strong,  as  is  usually  the  case  when 
the  opening  is  onh^  the  exposure  of  one  of  the  horns  of  the  pulp, 
the  better  way  is  to  enlarge  the  opening  with  a  fissure  bur.     This 


TREATMENT    OF    THE    DENTAL   PULP.  311 

should  be  passed  into  the  pulp  chamber  through  the  orifice  of 
the  exposure,  and  when  the  operator  is  sufficiently  sure  in  his 
knowledge  of  the  anatomy,  he  may  cut  around  the  pulp  chamber 
parallel  with  its  axial  walls  and  remove  the  covering  in  a  single 
piece.  Otherwise  the  opening  may  be  enlarged  by  carrying  the 
bur  laterally  toward  the  central  portion  of  the  covering  of  the 
chamber  and  then  carrying  it  around  in  a  circle.  Then  hoe 
6-2-23  may  be  passed  into  the  opening  and  its  blade  turned  under 
the  occlusal  wall  of  the  pulp  chamber,  the  overhang  determined, 
and  the  cutting  directed,  until  the  whole  extent  of  the  chamber  is 
uncovered.  No  overhang  should  be  left  at  any  point.  In  this 
cutting,  the  greatest  care  should  be  taken  that  the  bur  be  not 
pressed  into  the  floor  of  the  chamber  and  its  form  marred.  It  is 
best  to  prepare  a  number  of  small  fissure  burs  especially  for  this 
by  grinding  the  ends  smooth  on  a  stone,  while  rapidly  rotating 
in  the  engine.  With  these  there  will  be  no  danger  of  marring 
the  floor  of  the  pulp  chamber.  When  the  whole  of  the  covering 
has  been  removed,  it  is  generally  best  to  enlarge  somewhat 
toward  the  mesio-buccal  angle  in  order  to  give  better  access  to 
the  mesio-buccal  root  canal.  This  may  be  done  most  readily 
and  in  the  best  form  by  a  scraping  movement  with  the  cleoid 
excavator. 

The  case  is  now  ready  for  the  removal  of  the  pulp.  Inci- 
dentally much  of  the  tissue  of  the  bulb  of  the  pulp,  possibly  all 
of  it,  will  have  been  removed  in  doing  this  cutting,  but  no  attempt 
should  be  made  to  remove  the  pulp  from  the  canals  until  this 
cutting  is  satisfactorily  completed  and  the  cavity  cleared  of  all 
dentin  chips  and  cuttings.  If  this  is  neglected,  it  will  often 
happen  that  these  cuttings  will  get  into  the  smaller  root  canals 
and  stop  them  so  that  they  can  not  again  be  opened.  For  this 
reason  all  cutting  in  opening  the  pulp  chamber,  especially  in 
bicuspids  and  molars  in  which  some  of  the  canals  are  often  very 
small,  should  be  fully  completed  before  any  effort  is  made  to 
remove  the  pulp  from  the  canals.  When  in  any  case  it  is  found 
that  more  cutting  for  access  to  some  one  root  canal  must  be  made, 
a  bit  of  cotton  should  be  placed  loosely  in  the  root  canals  that 
have  been  opened,  to  remain  while  the  cutting  is  being  done  and 
until  the  cavity  is  again  freed  from  cuttings.  Tlion  with  the 
removal  of  this  cotton  the  last  of  the  cuttings  will  bo  removed. 

In  many  cases,  after  the  first  opening  has  been  made,  the 
occlusal  wall  of  the  pulp  chamber  can  be  cut  away  more  quickly 
with  the  chisel  and  mallet. 


312  SPECIAL   DENTAL   PATHOLOGY. 

Proximal  cavities  in  molars.  If  the  exposure  is  from  a 
mesial  cavity,  the  entting  will  be,  of  course,  to  the  distal  and 
often  will  involve  the  removal  of  the  middle  third  of  the  occlusal 
surface  with  the  whole  of  the  dentin  intervening  between  it  and 
the  pulp.  If  a  distal  cavity,  the  middle  third  bucco-lingually  of 
the  occlusal  surface,  with  the  intervening  dentin,  should  at  once 
be  removed  to  a  point  well  toward  the  mesial  marginal  ridge. 

Cavities  in  bicuspids.  In  the  bicuspids  the  exposures  are 
almost  uniformly  from  cavities  in  the  proximal  surfaces,  and 
the  pulp  chambers  are  broad  bucco-lingually.  The  cutting  for 
opening  the  pulp  chamber  must  be  directed  first  to  the  central 
part  of  the  crown,  but  later  broadened  from  buccal  to  lingual ; 
for  the  horns  of  the  pulp  when  long  are  inclined  toward  the 
points  of  the  cusps,  as  in  Figure  365.  These  horns  should  be 
fully  opened  so  that  they  may  be  cleaned  and  solidly  tilled.  The 
root  canals  in  these  teeth,  especially  in  the  upper  first  bicuspids, 
are  given  off  from  the  extreme  buccal  and  extreme  lingual  por- 
tions of  the  chamber,  as  shown  in  Figiire  365,  and  unless  the 
cutting  is  broad  in  these  directions,  the  broach  will  not  have 
direct  entrance  into  them. 

CA^aTiES  IN  INCISORS  AND  CUSPIDS.  lu  the  incisoTs  and  cus- 
pids, exposures  are  generally  from  proximal  cavities.  In  open- 
ing these  for  the  removal  of  the  pulp,  the  orifice  of  the  exposure 
should  be  first  extended  to  the  gingival  wall  of  the  cavity  and  to 
the  full  breadth  of  the  chamber.  The  approach  should  be  care- 
fully considered.  Generally  a  broach  will  not  readily  slide  into 
the  canal  without  being  bent  more  or  less.  (See  Figure  366.) 
This  is  unfavorable,  and  a  better  approach  must  be  made. 
A^Hien  a  cavity  is  so  large  that  the  pulp  has  been  reached,  the 
lingual  wall  should  generally  be  cut  away,  and  this  will  improve 
the  approach,  the  instrument  being  passed  to  the  lingual  of  the 
incisal  edge  of  the  tooth;  rarely  the  labial  wall  should  be  cut 
away.  The  approach  may  be  improved  still  more  by  taking  a 
small  fissure  bur  in  the  engine,  and,  approaching  the  canal  from 
the  direction  in  which  a  broach  would  be  introduced,  passing  it 
into  the  canal  and  cutting  by  lateral  pressure,  broaden  the  canal 
in  a  direction  to  straighten  the  approach,  as  shown  in  Figure  367. 
This  cutting  will  be  toward  the  disto-lingual  if  a  distal  cavity, 
or  mesio-lingual  if  a  mesial  cavity,  if  the  approach  is  to  the 
lingual  of  the  incisal  edge.  From  whatever  the  direction  of  the 
approach,  the  cutting  is  to  be  so  directed  to  the  broadening  of 
the  incisal  portion  of  the  canal  that  the  broach  will  reach  the 


TREATMENT    OF    THE    DENTAL    PULP.  313 

apex  of  the  tooth  with  the  least  bending.  In  this  cutting,  special 
care  should  be  taken  that  the  end  of  the  bur  does  not  cut  the 
opposite  side  of  the  canal  and  roughen  it,  for,  if  it  should,  the 
point  of  the  broach  may  catch  in  the  rough  points  at  every 
effort  to  introduce  it  into  the  canal.  By  this  cutting  the  curve 
of  the  instruments  introduced  into  the  canal  for  the  removal  of 
the  pulp,  or  for  filling  the  canal,  will  be  much  less  abrui)t  and 
these  operations  can  be  done  more  perfectly. 

Removal  of  the  pulp. 

Broaches,  The  instruments  used  for  removing  the  pulp 
from  the  canals  are  the  barbed  broach  and  the  smooth  broach. 
Generally  the  barbed  broach  should  be  used  first.  Usually  the 
bulb  of  the  pulp  will  have  been  removed  during  the  opening  of 
the  pulp  chamber,  and  the  broach  selected  should  be  suited  in 
size  to  the  canal.  Each  broach  should  be  tested  before  using  it 
by  placing  the  end  against  the  bottom  of  the  glass  dish  with 
sufficient  pressure  to  bend  it  so  that  the  point  will  be  at  a  right 
angle  to  the  handle,  at  the  same  time  rotating  the  broach.  It 
should  bend  in  a  regnilar  curve.  Occasionally  in  cutting  the 
barbs,  the  shaft  is  cut  too  deeply  at  some  point,  which  will  cause 
it  to  break  easily;  such  a  broach  should  be  discarded.  The 
])roach  should  generally  be  held  in  a  light  handle,  but  may  be 
used  without.  Just  before  introducing  the  broach,  it  should  be 
sterilized  by  immersing  it  in  phenol  and  then  washing  it  in 
alcohol,  as  has  been  described.  There  should  be  enough  of  these 
medicaments  so  that  the  worldng  part  of  the  broach  can  be 
effectively  washed. 

It  is  not  meant  that  this  dipping  of  a  broach  in  the  medica- 
ments mentioned  is  sufficient  sterilization  for  a  broach  which 
has  been  used  previously.  I  would,  however,  consider  this  pro- 
cedure safe  for  a  new  broach,  or  one  which,  after  having  been 
used,  had  been  properly  sterilized  and  then  laid  aside. 

After  a  broach  has  been  used  it  should  first  be  cleaned  of  all 
shreds  of  tissue  ])y  the  use  of  a  stiff  brush.  If  a  wire  brush  is 
used  for  this  purpose,  the  motions  in  cleaning  should  be  from 
the  point  of  the  broach  toward  the  handle,  thus  avoiding  dulling 
the  sharp  barbs.  The  broach  may  then  be  immersed  for  a  time 
in  phenol,  or  some  strong  antiseptic,  in  a  dish  kept  for  the  ])ur- 
pose.  Upon  removing  the  In'oach  from  the  ])henol,  it  should  be 
washed  in  alcohol,  and  put  away  in  a  small  glass  bottle.  Several 
bottles  should  be  used  for  this  purpose,  so  that  the  different 
sizes  may  ])e  kept  sorted. 

29 


314  SPECIAL   DENTAL   PATHOLOGY. 

As  a  general  rule  I  think  it  is  the  most  satisfactory  and 
economical  i)lan  to  use  a  new  broach  for  the  removal  of  each 
puljx  Often  several  new  ones  should  be  used  in  molar  teeth. 
This  sharp  broach  will  usually  bring  away  practically  the  entire 
pulp  at  once,  while  a  dull  broach  may  bring  only  a  part,  thus 
increasing  the  difficulty  of  removing  the  remainder,  and  adding 
much  to  the  time  required  for  the  operation.  Used  broaches 
may  be  employed  for  removing  dressings  previously  placed,  or 
for  pulp  removal,  depending  on  the  sharpness  of  the  barbs. 

Technic  of  eemoval.  The  broach  should  be  passed  into  the 
canal,  the  point  being  directed  against  one  of  the  walls  so  that  it 
will  pass  in  beside  the  pulp  tissue  rather  than  through  it. 
Oenerally  the  point  should  be  pushed  to  the  apical  foramen  and 
then,  if  it  is  felt  to  be  held  tightly  in  the  apical  end  of  the  canal, 
withdrawn  until  it  is  felt  to  be  loose.  The  broach  should  then 
l)e  rotated  lightly,  moving  it  slightly  back  and  forth  to  be  sure 
that  the  whole  length  is  rotating  and  not  being  held  in  some 
curved  part  of  the  canal  which  would  be  liable  to  break  the 
broach.  The  rotation  should  not  exceed  one  turn.  The  broach 
should  then  be  withdrawn.  In  a  good  many  cases  the  entire 
contents  of  the  canal  will  be  brought  away  with  the  first  effort. 
If  not,  the  movement  should  be  repeated.  Sometimes  the  tissue 
of  the  pulp  will  break  up  into  shreds  and  be  but  partially 
removed.  In  such  cases,  the  smooth  broach  with  cotton  should 
be  used. 

After  the  removal  of  the  pulp,  a  mild  antiseptic,  such  as  oil 
of  cloves  or  "1-2-3,"  should  be  sealed  in  the  canal.  Cotton, 
properly  wrapped  on  a  broach,  should  be  saturated  with  the 
desired  drug,  and  the  excess  removed  between  the  folds  of  a  piece 
of  sterile  gauze  before  being  placed  in  the  canal.  One  end  of 
the  cotton  wisp  should  project  into  the  pulp  chamber  in  order 
that  it  may  readily  be  removed  at  another  sitting.  This  should 
be  covered  with  a  pellet  of  cotton  similarly  treated  and  the 
cavity  sealed  with  gutta-percha. 

Location  of  canals  in  upper  molars.  Difficulty  often 
occurs  in  finding  the  canals  in  the  molar  teeth.  The  difficulty  is 
generally  because  the  floor  of  the  pulp  chamber  has  been  muti- 
lated with  burs  and  the  openings  of  the  canals  filled  with  chips. 

The  floor  of  the  pulp  chamber  is  rounded  or  arched  in  the 
center  and  falls  away  toward  the  mouths  of  the  canals.  In 
upper  molars,  the  canals  are  situated  in  the  position  of  the 
angles  of  a  triangle  (the  molar  triangle),  shown  in  Figures  368 
and  369,  the  mesial  lino  of  which  is  the  longest,  the  buccal  the 


TREATMENT   OF   THE   DENTAL   PULP.  315 

shortest,  and  tlie  distal  the  intermediate  length.  For  the  first 
molar,  this  triangle  is  well  shown  in  the  illustrations  represent- 
ing sections  a  little  rootwise  from  the  floor  of  the  pulp  chamber. 
This  is  best  seen  in  the  specimen  itself;  and  the  position  and 
the  direction  of  the  canals,  with  relation  to  the  walls  of  the  pulp 
chamber  and  the  main  points  of  the  surface  of  the  crown,  should 
be  carefully  studied. 

The  opening  into  the  lingual  root  is  the  simplest  and  most 
direct.  Generally,  the  canal  begins  in  a  funnel-shaped  opening 
inclining  to  the  lingual,  as  in  Figure  371,  which  quickly  narrows 
to  the  dimensions  of  a  moderately  small  canal  and  continues  to 
taper  to  the  apical  foramen.  It  is  usually  very  nearly  straight. 
The  approach  to  the  canal  with  the  broach  is  from  the  buccal, 
with  a  lingual  inclination.  The  broach  should  be  placed  against 
the  lingual  wall  and  slid  forward  until  it  glides  into  the  canal. 

The  opening  of  the  mesio-buccal  canal  is  under  the  mesio- 
buccal  cusp,  close  against  the  mesio-buccal  angle  of  the  pulp 
chamber.  It  often  happens  that  this  canal  opens  in  a  groove  in 
the  angle  of  the  chamber,  Figures  368  and  369,  making  this  the 
thinnest  point  in  the  dentinal  walls  surrounding  it.  In  young 
teeth,  the  mouth  of  the  canal  is  of  a  flattened  funnel  shape,  which 
is  quickly  contracted  into  a  very  fine  canal ;  but  in  the  adult  it 
often  begins  as  a  fine  canal.  Its  course  at  first  is  to  the  buccal 
and  mesial  and  then  to  the  distal.  It  is  usually  distinctly  flat- 
tened and  often  has  a  thin  edge  to  the  lingual.  It  is  often  a  very 
difficult  canal  to  clean  with  a  broach.  To  find  this  canal,  the 
point  of  the  broach  should  be  directed  into  the  mesio-buccal  angle 
of  the  pulp  chamber,  and  while  held  against  the  wall  within  this 
angle,  should  be  slid  toward  the  root.  It  will  rarely  fail  to  glide 
into  the  canal. 

The  disto-buccal  canal  usually  begins  abruptly  as  a  fine 
opening,  situated  at  the  disto-buccal  angle  of  tlie  floor  of  the 
X)ulp  chamber.  Figures  368  and  369,  so  that  a  broach  pressed 
into  that  angle  w^ill  easily  glide  into  it.  But  in  some  instances, 
especially  in  the  upper  second  molars,  the  opening  is  in  the  floor 
of  the  pulp  chamber  at  a  little  distance  from  the  immediate  angle 
toward  the  center  of  the  floor,  and  then,  in  positions  which  limit 
\dsion,  it  is  often  difficult  to  find.  In  teeth  much  flattened  at  the 
neck,  the  opening  of  this  canal  may  begin  voiy  close  to  the  mouth 
of  the  mesial  canal,  Figure  370,  or  close  against  the  distal  wall, 
or,  anywhere  between  this  point  and  the  disto-buccal  angle.  The 
first  direction  of  the  canal  will  vary  according  to  its  position. 
If  it  is  found  in  a  fairly  well-defined  disto-buccal  angle  of  the 


316  SPECIAL   DENTAL,    PATHOLOGY. 

chamber,  its  direction  will  be  a  little  inclined  to  the  distal  and  the 
broach  will  penetrate  it  easily ;  if  in  the  floor  of  the  chamber,  it 
will  sometimes  be  straight,  as  in  the  former  case;  but,  more 
generally,  the  first  direction  will  be  to  the  distal  and  buccal, 
with  considerable  curve  afterward.  If  found  close  to  the  mesial 
canal,  its  course  is  usually  first  sharply  to  the  distal,  when  it 
swerves  rather  abruptly  toward  the  apex  of  root.  If  found 
along  a  smooth  or  curv'ed  distal  wall,  the  course  will  generally  be 
to  the  distal  and  buccal  with  but  little  curve.  This  canal  is 
usually  very  fine  from  its  beginning,  and  almost  or  quite  round. 

While  the  canals  are  similar  in  all  of  the  upper  molars,  there 
are  differences  in  the  form  of  the  floor  of  the  pulp  chamber  that 
may  be  briefly  generalized.  The  pulp  chamber  of  the  upper 
second  molar.  Figure  374,  is  usually  much  more  flattened  mesio- 
distally  than  that  of  the  first  molar.  This  changes  the  relation 
of  the  openings  of  the  canals  somewhat,  rendering  the  distal 
angle  of  the  triangle  formed  by  them  more  obtuse  and  brings  the 
opening  of  the  distal  canal  nearer  the  mesial  line  of  the  triangle, 
so  that  it  seems  to  be  found  along  the  distal  wall  of  the  narrowed 
chamber.  In  others,  it  is  found  in  the  extreme  buccal  portion 
crowded  close  against  the  mouth  of  the  mesial  canal. 

The  position  of  the  openings  of  the  canals  in  the  upper  third 
molar.  Figures  376  and  377,  is  usually  much  the  same  as  in  the 
first  and  second,  varying  so  as  to  resemble  either.  Occasionally 
there  are  more  than  the  usual  number ;  occasionally  only  one  or 
two  canals.  When  there  is  but  one,  it  is  commonly  quite  large. 
Four,  five,  or  even  seven  or  eight,  are  sometimes  found. 

Location  of  canals  in  lower  molars.  The  pulp  chambers 
of  the  lower  molars.  Figures  378  to  388,  have  the  same  general 
form  as  the  surface  of  the  crowns,  but  are  generally  rather  more 
angular.  The  wall  of  the  chamber  toward  the  occlusal  surface 
is  convex  toward  the  pulp ;  the  horns  extend  from  the  extreme 
angles  toward  the  apex  of  each  cusp.  The  floor,  through  the 
central  portion,  is  arched  or  convex  from  mesial  to  distal,  and 
concave  from  buccal  to  lingual.  The  mesial  wall  of  the  cavity 
is  flat  and  longer  than  the  distal,  which  is  rounded  or  con- 
cave. The  mesio-buccal  and  mesio-lingual  angles  are  sharp  and 
projecting,  while  the  distal  angles  are  rounded,  Figure  381.  The 
size  of  the  chamber  varies  much.  In  youth,  its  diameter  is  often 
as  much  as  two-fifths  of  the  crown  and  seldom  less  than  one- 
third.  This  diminishes  as  age  advances,  and  in  old  age  it  is 
often  very  small ;  especially  where  there  has  been  considerable 


Fig.  364. 


Fig.  36.5. 


Fig.  366. 


Fig.  367. 


Fig.  364.  KcuKiviiiff  softened  iiiateriiil  witli  si)oon  20-9-12.  In  this  ease  tliis  is 
clone  befoie  squarin^r  uji  llie  dentin  walls  hecanse  there  is  believed  to  l)c  tianger  of 
exposing  the  pulp. 

Fig.  365.  A  i)hotogiaph  of  a  second  bicuspid  s]dit  bucco-lingually  to  show  the 
form  of  the  pulp  chamber.  This  patient  was  about  fifteen  years  of  age  and  the 
illustration  shows  about  the  extreme  bucco-iingiial  breadth  of  the  j)ulp  chamber  in 
young  persons.  In  this  case  the  horns  of  the  pulp  are  rounded,  but  they  are  often 
pointed.  This  case  illustrates  the  cutting  biu'co-lingually  which  is  often  necessary 
to  fully  expose  and  clean  these  puiji  chambers.  Every  jiart  of  the  puli)al  horns  should 
be  exposed.     Tlie  dentin  was  tinged  with  eosin  to  sharply  distinguish  the  enanud  cap. 

Fig.  366.  An  outline  drawing  of  a  central  incisor,  with  an  excavated  cavity 
exposing  the  pulp,  split  mesio-distally  to  show  the  relations  to  the  pulp  chamber  and 
canal  to  the  cavity.  The  canal  and  chamber  are  of  such  breadth  as  is  usually  found 
in  young  persons.  Jt  will  be  seen  that  it  wouM  be  ditlicult  to  pass  a  broach  to  the 
apex  of  the  root  canal  because  of  the  short  bend  that  w(nild  be  re(|iiired  in  entering 
the   pulp  chamber. 

Fig.  367.  A  fissure  bur  is  entered  into  tlic  opening  into  tlie  pulp  chamber  and 
the  canal  enlarged,  as  shown,  in  such  direction  as  to  make  the  use  of  the  broach  easy. 
The  canal  is  then  cleaned  witli  much  more  ease  and  certainty  of  the  complete  removal 
of  the  pulp. 


*29 


Fig.  368.  Fig.  369. 

Fig.  370.  Fig.  371.  Fig.  372.  Fig.  373. 

Id  tt 

Fig.  374.  Fig.  375.  Fig.  376.  Fig.  377. 


Figs.  368,  369.  Each  of  these  represents  three  horizontal  sections  across  the  neck 
and  root  of  an  upper  first  molar.  The  first  in  each,  reading  from  left  to  right,  is 
through  the  central  part  of  the  pulp  chamber.  The  second  is  at  the  point  where 
the  canals  are  dividing  from  the  chamber.  The  third  section  is  a  little  rootwise  from 
the  pulp  chamber  and  shows  the  molar  triangle,  formed  by  the  relative  position  of  the 
canals,  to  advantage.  This  exhibits  the  relation  of  the  root  canals  to  the  pulp 
chamber. 

Figs.  370  to  373.  Lengthwise  sections  of  upper  first  molars  exhibiting  the  rela- 
tion of  the  root  canals  to  the  pulp  chamber. 

Fig.  370.  A  section  exposing  the  pulp  chamber  and  the  canals  in  the  mesio-  and 
disto-buccal  roots. 

Fig.  371.  A  section  exposing  the  pulp  chamber  and  mesio-buccal  and  lingual 
root  canals. 

Fig.  372.    Another  section  exposing  the  two  buccal  root  canals. 

Fig.  373.  A  section  exposing  the  pulp  chamber  and  the  canals  in  the  disto- 
buccal  root  and  the  lingual  root. 

Fig.  374.  A  perpendicular  section  of  an  upper  second  molar,  exposing  the  pulp 
chamber  and  the  canals  in  the  mesio-  and  disto-buccal  roots. 

Fig.  37.5.  A  perpendicular  section  of  an  upper  second  molar,  exposing  the  pulp 
chamber  and  the  canals  in  the  disto-buccal  and  lingual  roots. 

Figs.  376,  377.  The  pulp  chamber  and  root  canals  in  upper  third  molars. 
Figure  376  is  a  bucco-lingual  section  showing  the  canals  in  the  messio-buccal  and 
lingual  roots.  Figure  377  is  a  mesio-distal  section  showing  the  divided  buccal  canals 
in  a  tooth  with  a  single  root. 


n0  QSS:: 

Fig.  378.        Fig.  379.  Fig.  380.  Fig.  381. 

Fig.  38-J.       Fig.  383.  Fio.  384.  Fig.  385. 

Fig.  386.  Fig.  387.         Fig.  388. 


Figs.  378,  379.  Mesio-distal  sections  of  lower  first  molars,  exposing  the  pulp 
chamber  and  root  canals. 

Fig.  380.  A  bucco-lingual  section  through  the  mesial  root  of  a  lower  first  molar, 
showing  the  pulp  chamber  and  the  two  canals  in  the  mesial  root.  Not  very  infre- 
quently these  end  in  a  common  apical  foramen. 

Fig.  381.  Six  cross  sections  through  the  central  part  of  the  pulp  chambers  and 
the  roots  of  two  lower  molar  teeth.  The  second  cut  is  just  below  the  pulp  chamber  in 
each.  The  third  cut  is  about  midlength  of  the  roots.  In  the  upper  series,  the  mesial 
root  has  one  broad  canal.  In  the  lower  series  this  is  divided  into  two  very  small 
canals,  widely  separated. 

Fig.  382.  A  mesio-distal  section  of  a  lower  second  molar  with  a  single  root, 
showing  the  pulp  chamber  and  a  mesial  and  a  distal  root  canal. 

Fig.  383.  A  bucco-lingual  section  of  a  lower  second  molar  with  one  root  and  one 
large  pulp  canal. 

Fig.  384.  A  mesio-distal  section  of  a  lower  second  molar  with  two  roots,  showing 
the  root  canals. 

Fig.  385.  A  bucco-lingual  section  of  the  crown  and  mesial  root  of  a  lower  second 
molar,  with  two  root  canals  which  join  in  the  apical  third  of  their  length  and  again 
separate,  ending  in  separate  apical  foramina.     This  is  unusual. 

Figs.  386,  387,  388.  Mesio-distal  sections  of  lower  third  molars,  showing  the 
forms  of  the  pulp  chambers  and  root  canals.  Figure  387  shows  the  single  root  with 
one  large  canal.     This  is  not  very  uncommon  in  these  teeth. 


Pig.  3S9. 


Fig.  389.  Photograph  showing,'  tho  position  for  passing  a  broach  into  the  canal 
of  the  distal  root  of  any  one  of  the  hiwcr  iiiohirs.  Tlio  removal  of  the  pulp,  the 
cleaning  and  filling  of  iliis  parti.-ulai  canal  is  done  best  from  about  this  position. 


TREATMENT   OF   THE   DENTAL   PULP.  317 

abrasion  of  the  teeth,  the  pulp  chamber  may  be  ahiiost  or  quite 
obliterated. 

The  root  canals  of  the  lower  molars  proceed  from  the  mesial 
and  distal  portions  of  the  pulp  chamber,  Figures  378,  379,  381, 
384,  386  and  388.  The  mesial  canal,  at  its  mouth,  is  usually 
about  as  broad  from  buccal  to  lingual  as  the  whole  breadth  of 
the  chamber,  including  its  angular  projections.  Either  at,  or  a 
little  rootwise  from,  the  floor  of  the  pulp  chamber,  it  is  usually 
divided  into  two  very  small  canals  which  diverge  at  first,  and 
approach  each  other  afterward,  but  usually  remain  distinct,  each 
ending  in  its  own  apical  foramen,  Figure  380.  Occasionally, 
however,  they  are  united  in  the  apical  third  of  the  root,  and  end 
in  a  common  apical  foramen.  Again,  there  may  be  a  communi- 
cation between  them  in  the  apical  portion  of  the  root,  each  canal 
remaining  otherwise  complete  in  itself,  Figure  385.  A  few  have 
one  broad  flattened  canal,  Figure  381.  These  canals  are  usually 
minute  and  very  difficult  to  thoroughly  clean  with  the  broach, 
though  the  mesio-buccal  canal  is  usually  easily  found  if  the  pulp 
chamber  is  thoroughly  opened.  By  placing  the  point  of  the 
broach  in  the  mesio-buccal  angle  of  the  chamber  and  pushing  it 
gently  on,  it  will  generally  glide  into  the  canal.  The  first  direc- 
tion inclines  to  the  mesial  and  buccal,  after  which  it  curves  to  the 
distal  and  lingual.  Generally,  these  curves  are  easy,  without 
short  bends.  The  broach  glides  into  the  mesio-lingual  canal  by 
l^lacing  the  point  in  the  mesio-lingual  angle  of  the  pulp  chamber 
and  sliding  it  toward  the  root.  The  first  inclination  is  to  the 
mesial,  but  occasionally  to  the  lingual,  after  which  it  curves  to 
the  distal  and  buccal. 

The  distal  canal  is  approached  by  a  funnel-shaped  opening, 
of  which  the  central  part  of  the  distal  wall  of  the  pulp  chamber 
becomes  a  portion.  Its  direction  is  a  little  to  the  distal,  and  is 
generally  very  nearly  straight  to  the  apex.  At  first  it  is  flat- 
tened with  the  long  diameter  from  buccal  to  lingual,  and  pro- 
gressively becomes  rounded  and  tapers  regularly  to  the  apical 
foramen.  It  is  generally  much  larger  than  the  canals  of  the 
mesial  root  and  is  easily  cleaned  with  the  broach.  If  the  mouth 
of  the  patient  is  wide  open  and  the  handle  of  the  broach  ])rought 
against  the  upper  central  incisors  with  the  point  directed  against 
the  posterior  wall  of  the  pulp  chamber,  it  will  easily  glide  into 
the  canal  and  pass  to  the  apical  foramen.  This  position  is  shown 
in  the  photograph,  Figure  389.  This  particular  position  for 
easily  entering  the  distal  canal  is  applicable  to  all  the  lower 
molars.     Occasionally,  the  lower  third  molar  has  but  one  root 


318  SPECIAL   DENTAL   PATHOLOGY. 

canal,  Figure  387,  wliicli  is  genorally  very  large.  More  rarely 
only  a  single  canal  will  be  found  in  the  lower  second  molar ;  but 
generally,  the  canals  of  the  second  and  third  lower  molars  are 
similar  to  those  of  the  first.  The  pulp  chambers  are  usually 
smaller  and  oftener  irregular  in  outline.  The  lower  third  molar 
has,  occasionally,  a  very  large  pulp  chamber. 

Variations  of  the  forms  of  pulp  chambers.  Manj^  varia- 
tions of  form  occur  in  the  pulp  chambers  and  root  canals.  The 
roots  of  the  teeth  may  be  abnormally  crooked.  In  many 
instances,  the  pulp  chamber  will  have  in  it  secondary  forma- 
tions, called  nodules,  which  may  be  adherent  to  the  walls  or  block 
the  openings  of  the  canals  and  prevent  a  broach  from  gliding 
into  them.  These  also  occur,  occasionally,  within  the  canals, 
partially  blocking  the  way  of  the  broach.  Sometimes  the  pulp 
chamber  will  be  filled  with  nodular  deposits  so  completely  that 
there  seems  to  be  no  room  for  the  tissues  of  the  pulp.  These 
deposits  must  be  removed  before  the  root  canals  can  be  reached 
and  entered,  after  which  the  canals  will  generally  be  found  open. 
Such  deposits  occur  within  the  pulp  chambers  of  any  of  the 
teeth,  but  they  cause  annoyance  most  frequently  in  the  molars. 

Occasionally  lateral  openings  occur  from  the  root  canals  to 
the  surface  of  the  root.  More  of  these  have  been  seen  from  the 
canals  of  the  lower  molars  than  any  other  teeth.  Generally  they 
follow  the  course  of  the  dentinal  tubules  and  open  on  the  side  of 
the  root.  They  may  diverge  to  one  side  and  curve  toward  the 
apex  of  the  root.  These  can  not  often  be  detected,  exce])t  in 
dissections  of  the  root,  and  occur  so  rarely  they  may  be  ignored 
in  practice. 

Sometimes  the  horns  of  the  pulp  approach  abnoi*mally  near 
the  points  of  the  cusps  of  some  of  the  teeth,  as  in  the  upper  first 
bicuspid,  and  in  the  mesio-buccal  cusp  of  the  upper  first  molar. 
Then  the  pulp  is  more  liable  to  exposure  in  excavating  carious 
cavities. 

Opening  pulp  chambers  in  sound  teeth. 

Frequently  it  is  necessary  to  open  the  pulp  chambers  of 
teeth  that  are  sound,  or  that  have  fillings  previously  inserted, 
the  removal  of  which  is  not  indicated.  The  pulp  may  be  dead 
or  in  such  a  condition  of  disease  that  it  should  be  removed. 
In  these  cases,  it  becomes  necessary  to  cut  from  the  surface  of 
the  tooth  or  through  the  filling. 

In  incisors  and  cuspids.  In  case  of  the  incisors  or  cuspids, 
the  best  place  to  enter  the  pulp  chamber  is  through  the  central 


TREATMENT    OF    THE    DENTAL    PULP.  319 

portion  of  the  lingual  surface.  For  this  purpose,  a  bibeveled 
drill,  one  millimeter  in  diameter,  should  be  first  used.  Its  cut- 
ting edges  should  be  very  sharp.  With  this  the  enamel  should 
be  i3enetrated  and  the  drill  forced  a  little  distance  into  the  dentin. 
This  opening  should  be  considerably  enlarged  by  a  larger  drill 
or  a  round  bur.  Then  the  small  drill  should  be  forced  ahead 
and  by  several  changes  of  these  instruments  the  pulp  chamber 
may  be  reached.  The  point  of  the  small  drill  should  never  pene- 
trate very  deeply  in  the  small  hole.  Neglect  of  this  precaution  is 
liable  to  cause  unnecessary  pain,  or  to  break  the  point  of  the 
drill  by  some  quick  movement  of  the  patient.  If  the  pulp  is 
alive  and  sensitive,  it  should  now  be  destroyed.  Afterward  the 
complete  opening  of  the  chamber  may  be  proceeded  with.  If  the 
pulp  is  dead,  the  further  opening  of  the  chamber  may  be  done  at 
once. 

In  cutting  into  the  pulp  chamber  through  the  lingual  sur- 
face of  incisors,  the  drill  has  entered  from  the  lingual  at  a  con- 
siderable inclination,  as  shown  in  Figure  390,  and  it  is  necessary 
to  make  the  opening  as  nearly  parallel  with  the  length  of  the  pulp 
canal  as  practicable.  To  do  this,  a  fissure  bur  should  be  used. 
Its  end  should  be  passed  into  the  pulp  chamber  and  the  hand- 
piece brought  slowly  parallel  with  the  long  axis  of  the  tooth, 
cutting  from  the  incisal  wall  of  the  opening  first  made,  as  shown 
in  Figure  391 ;  then  with  the  same  instrument  passed  farther  in, 
the  lingual  wall  of  the  pulp  chamber  should  be  cut  away,  going 
deeper  into  the  root  canal  carefully,  so  as  not  to  mar  the  labial 
side,  until  the  fonn  shown  in  Figure  392  is  obtained.  This 
cutting  should  be  sufficient  to  admit  a  broach  to  the  full  length 
of  the  canal,  with  a  very  little  bending.  Unless  there  is  reason 
for  delay,  as  on  account  of  soreness  of  the  tooth,  the  incisal 
end  of  the  pulp  chamber,  which,  as  in  Figure  392,  can  not  be 
reached  for  cleaning  or  filling,  should  l)e  opened  by  cutting  away 
the  tissue,  as  shown  in  Figure  393.  This  should  always  be  done 
before  a  filling  is  made.  Otherwise  a  little  tissue  or  debris  will 
be  left,  which  will  decompose  later  and  discolor  the  tooth.  It  is 
also  necessary  that  this  be  opened  so  that  it  may  be  solidly  filled. 
When  this  has  been  completed,  the  cleaning  and  treatment  of  the 
canal  can  be  proceeded  with. 

Generally,  when  incisors  have  proximal  fillings  that  are 
good,  the  opening  into  the  pulp  should  be  made  from  the  lingual, 
as  al)Ove  described,  without  distur])iiig  the  fillings.  If,  how- 
ever, there  is  reason  for  removing  a  proximal  filling,  the  i^ilp 
chamber  should  be  opened  tlirough  the  cavily. 


320  SPECIAl.   DENTAL   PATHOLOGY. 

The  different  teeth  of  each  class  show  much  variation  in 
form  and  position,  which  makes  considerable  differences  in  the 
cutting  necessary  to  so  straighten  the  line  of  approach  that  the 
broach  and  the  root  canal  plugger  will  go  easily  to  the  apex  of 
the  root  canal,  or  canals,  without  so  much  bending  as  to  inter- 
fere with  their  eifective  use.  Some  are  of  such  form,  and  the 
line  of  approach  is  such,  that  this  is  easily  obtained  while  others 
are  very  much  more  difl&cult.  But  in  almost  every  case  fairly 
free  working  of  these  instruments  can  be  obtained  by  judicious 
cutting,  which  will  not  be  excessive  in  lines  that  will  materially 
injure  the  strength  of  the  teeth.  As  the  future  usefulness  of  the 
teeth  will  depend  upon  the  effectiveness  of  the  treatment  of  the 
root  canals,  one  should  not  be  satisfied  to  undertake  this  withoiit 
the  best  access  for  these  instruments  that  can  be  reasonably 
obtained. 

In  bicuspids  and  molaes.  In  bicuspids  and  molars,  the 
o]iening  should  be  made  through  the  occlusal  surface.  In  bicus- 
pids the  mesial  pit  should  be  chosen.  In  molars  it  is  generally 
much  easier  to  penetrate  the  enamel  through  the  pit  in  the  cen- 
tral fossa.  In  this  case,  as  soon  as  the  dentin  has  been  entered 
it  is  best  to  introduce  a  small  inverted  cone  bur  and  cut  a  slot  to 
the  mesial  inclining  to  the  buccal,  and  chip  the  enamel  from  its 
margins.  The  length  of  this  toward  the  mesial  will  depend  on 
the  position  of  the  tooth  and  the  inclination  of  the  hand-piece  in 
drilling  through  the  dentin.  In  this,  the  object  is  to  gain  a  posi- 
tion from  which  the  drill  can  be  directed  into  the  pulp  chamber 
centrally  or  toward  its  mesial  portion.  The  dentin  is  thick,  and, 
in  passing  through  it  from  the  central  pit,  this  inclination  will 
often  carry  the  hole  considerably  to  the  distal.  Therefore,  in 
beginning  again  with  the  drill,  it  should  be  set  sufficiently  to  the 
mesial  so  that  it  will  strike  the  pulp  chamber  centrally,  or  to  the 
mesial  of  its  center,  as  stated.  In  drilling  through  the  dentin,  a 
small  drill,  one  millimeter  in  diameter,  should  first  be  made  to 
penetrate  a  little,  and  then  the  hole  enlarged,  then  drilled  deeper 
and  enlarged,  continuing  this  exchange  of  instruments  until  the 
dentin  has  been  cut  through.  It  should  be  recognized  that  there 
is  always  danger  that  a  small  drill  is  liable  to  clog  with  its  chips 
and  to  heat,  or  that  it  may  be  broken  and  the  end  remain  fast  in 
the  hole.  Or  some  sudden  movement  of  the  patient  may  break 
it.  For  these  reasons,  a  small  drill  should  not  be  sunk  very 
deeply  into  the  dentin  at  any  time  without  having  enlarged  the 
opening  through  which  it  works.  The  opening  should  not  be 
made  with  a  largo  drill  in  the  first  instance,  l)ecause  this  requires 


TREATMENT    OF    THE    DENTAL   PULP.  321 

too  much  force.  If  the  pulp  is  alive  and  sensitive,  it  should  be 
destroyed ;  if  dead,  the  opening  may  at  once  be  so  enlarged  as  to 
remove  the  entire  roof  of  the  pulp  chamber,  and  the  treatment 
of  the  canals  proceeded  with.  Treatment  of  pulp  canals  should 
never  be  undertaken  through  a  small  opening. 

In  a  considerable  number  of  cases  it  is  necessary  to  open 
the  pulp  chambers  of  bicuspid  and  molar  teeth  that  have  been 
filled.  If  the  fillings  are  good,  proceed  as  if  the  tooth  were  sound, 
cutting  through  the  filling,  or  through  the  dentin,  as  the  case 
demands.  If  there  is  reason  for  removing  the  filling,  do  so  at 
once,  and  open  the  pulp  chamber  through  the  cavity. 

Treatment  of  teeth  having  dead  pulps. 

Conditions  presenting.  Teeth  containing  dead  pulps  may 
present  in  any  of  the  following  conditions :  (1)  The  pulp  may  be 
dead  and  not  infected,  having  not  been  exposed  to  the  fluids  of 
the  mouth;  (2)  the  pulp  may  be  dead  and  infected,  without  hav- 
ing been  exposed  to  the  fluids  of  the  mouth ;  (3)  the  pulp  may  be 
dead  and  infected,  being  exposed  to  the  fluids  of  the  mouth. 
If  the  pulp  is  dead  and  not  infected,  the  soft  tissues  about  the 
apex  of  the  root  will  not  be  inflamed.  If  the  pulp  is  infected, 
there  may  be  no  disease  of  the  periapical  tissues,  or  there  may  be 
an  apical  pericementitis,  an  acute  alveolar  abscess,  a  chronic 
alveolar  abscess  with  a  sinus,  or  a  chronic  alveolar  abscess  with- 
out a  sinus  —  a  blind  abscess.  These  will  be  discussed  later, 
and  the  time  when  the  dead  pulp  should  be  removed  will  be 
considered  in  each  condition. 

Cases  in  which  the  pulp  is  dead  and  not  infected  are  neces- 
sarily cases  in  which  the  pulp  has  not  been  exposed  to  the  fluids 
of  the  mouth.  This  condition  occurs  most  frequently  from 
hyperemia  induced  by  thermal  shock,  less  often  by  accidental 
blows,  etc.  Those  cases  in  which  the  pulp  is  dead  and  infected, 
without  having  been  exposed  to  the  fluids  of  the  mouth,  occur 
from  the  same  causes,  the  infection  having  been  brought  to  the 
pulp  through  the  circulation.  There  is  an  occasional  case, 
closely  related  to  this  group,  in  which  the  pulp  dies  without 
having  been  exposed  to  the  fluids  of  the  mouth  by  a  cavity  of 
decay,  but  in  which  an  inflammation  of  the  peridental  membrane 
beginning  at  the  gingival  line  has  destroyed  the  attachment  of 
this  tissue  entirely  to  and  around  the  apex  of  the  root,  thus 
causing  the  death  of  the  pulp.  In  the  multirooted  teeth,  the 
pulp  may  be  cut  olT  and  infected  at  the  apex  of  one  root  and  yet 
more  or  less  of  the  pulp  tissue  will  be  kept  alive  for  a  consid- 

80 


322  SPECIAL   DENTAL   PATHOLOGY. 

erable  time  by  the  circulation  through  the  apices  of  the  other 
roots.  Such  a  pulp  may  give  a  definite  response  to  a  thermal 
test. 

Technic  of  TREATMENT.  AsEPsis.  In  Considering  the  tech- 
nic  of  treating  such  cases,  the  first  proposition  is  that  the  pulp 
chamber  and  root  canals  are  infected  districts,  which  are  to  be 
made  aseptic.  There  seems  to  be  a  sentiment  that  there  is  no 
need  of  aseptic  or  antiseptic  precautions  in  approaching  these, 
since  they  are  already  infected.  This  is  distinctly  wrong.  In 
the  great  majority  of  cases,  the  infections  are  with  the  mildly 
pathogenic  micro-organisms.  Root  canals  that  open  into  a 
cavity  of  decay  may  contain  saprophitic  micro-organisms  only, 
which  are  incapable  of  spreading  into  the  living  soft  tissues  by 
growth  and  producing  disease  in  that  way.  Their  products  of 
decomposition  in  the  root  canals  may,  however,  be  very  irri- 
tating and  cause  an  inflammation  when  passed  through  the  apical 
foramen.  In  any  of  these  cases  there  is  always  the  danger  of 
introducing  more  virulent  pathogenic  micro-organisms  during 
the  treatment,  unless  diligent  aseptic,  or  antiseptic  precautions 
are  employed  in  the  approach,  as  in  aseptic  cases.  There  should 
be  no  difference  in  this  respect  whatever  in  the  two  classes  of 
cases. 

Instrumentation.  The  instruments  used  in  cleaning  the 
canals  are  the  barbed  broach  and  the  smooth  broach  with  absor- 
bent cotton,  the  same  instruments  as  used  in  aseptic  cases.  The 
rubber  dam  must  protect  the  parts,  and  the  field  of  operation 
must  be  sterilized.  Then  if  the  canals  contain  fluid,  this  should 
be  carefully  absorbed  away  as  the  first  procedure  by  slight  wisps 
of  absorbent  cotton  wound  upon  the  smooth  broach.  This  should 
not  be  done  by  thrusting  in  as  much  cotton  as  the  root  canal  will 
hold,  for  the  reason  that  there  will  be  danger  of  pushing  the 
fluid  beyond  the  apical  foramen  and  causing  unnecessary  inflam- 
mation of  the  peridental  membrane.  Very  small  amounts  of 
cotton  should  be  used,  frequently  repeated,  and  the  fluid  lightly 
absorbed  into  these  and  drawn  away  without  pressure.  When 
the  canal  is  reasonably  dry,  a  barbed  broach  that  enters  the  canal 
loosely  should  be  introduced  carefully  some  little  distance  and 
withdrawn.  The  barbs  are  so  cut  that  they  hold  debris  or  shreds 
of  decomposing  tissue  on  the  pull  and  bring  away  any  such 
material  with  which  they  come  in  contact.  This  broaching 
should  be  continued,  washing  the  broach  repeatedly  in  the  phenol 
and  alcohol  mitil  the  canal  is  cleaned  to  its  apex.  During  this 
process  the  broach  should  be  inclined  this  way  and  that  in  its 


TREATMENT    OF    THE    DENTAL    PULP.  323 

withdrawal  so  as  to  effectively  scrape  all  parts  of  the  walls  of  the 
canal  with  barbs,  loosening  and  removing  all  adhering  particles. 
Finally,  the  canal  should  be  flooded  with  a  mild  antiseptic,  such 
as  ''1-2-3"  or  oil  of  cloves,  and  the  broaching  repeated.  The 
medicament  should  then  be  absorbed  away.  This  should  be 
repeated  until  the  canal  is  judged  to  be  well  cleaned.  Then  it 
should  be  dried  with  frequent  introduction  of  very  loosely  fitting 
bits  of  cotton  wound  upon  the  smooth  broach  and  so  rotated  as 
to  entangle  and  remove  any  particles  which  may  possibly  have 
been  left. 

Special  care  should  be  taken  that  the  cotton  on  the  smooth 
broach  shall  not  be  in  such  quantity  to  form  a  piston  that  will 
push  material  from  the  canal  through  the  apex  of  the  root  into 
the  tissues  beyond;  also  that  the  barbed  broach  be  not  used  in 
such  a  way  as  to  gather  shreds  of  material  before  it  and  push 
some  of  the  contents  into  the  tissue  beyond  the  apex  of  the  root. 
This  pushing  of  material  through  the  apex  of  the  canal,  which  is 
liable  to  produce  inflammation,  is  the  one  great  danger  in  clean- 
ing infected  root  canals.  It  is  to  be  especially  guarded  against. 
With  the  proper  sealing  of  the  cavity,  the  pulp  chamber  and  root 
canals  are  a  sealed  box,  the  disinfection  of  which  is  easily  com- 
manded. There  is  no  reason  whatever  for  the  use  of  irritating 
germicides  in  its  disinfection. 

Seal  treatment.  When  the  cleaning  has  been  completed,  a 
wisp  of  cotton  wrapped  on  a  broach  should  first  be  saturated  with 
the  desired  medicament  and  then  the  surplus  should  be  absorbed 
by  pressing  with  sterile  gauze  or  cotton,  so  that  the  danger  of  any 
of  the  drug  passing  through  the  foramen  will  be  reduced  to  the 
minimum.  This  should  be  placed  loosely  in  the  root  canal,  or  in 
each  root  canal,  when  there  are  more  than  one.  I  have  gener- 
ally preferred  beechwood  creosote  in  these  cases,  as  it  is  a  suffi- 
ciently strong  antiseptic  and  will  not  seriously  injure  the  apical 
tissues,  in  case  any  of  it  should  penetrate  the  foramen. 

Danger  of  periapical  infection.  As  mentioned  above,  the 
greatest  danger  in  cleaning  infected  root  canals  is  that  some  of 
the  infected  material  will  be  pushed  through  the  apex.  Some 
have  advocated  the  removal  of  only  a  part  of  the  infected  tissue 
at  the  first  sitting  and  the  placing  of  a  medicament  to  destroy 
the  micro-organisms  present  in  the  remainder,  removing  it  at 
the  second  appointment.  There  is  danger  of  causing  an  infec- 
tion of  the  periapical  tissues  by  either  plan.     The  pulp  tissue  is 


324  SPECIAL   DENTAL.   PATHOLOGY. 

usually  more  or  less  decomposed  and  where  the  pulp  is  only 
partly  removed  there  is  danger  of  forcing  some  of  the  remainder 
through  the  apical  foramen  in  sealing  the  cavity.  Under  either 
plan,  the  most  careful  technic  should  be  employed. 

It  has  been  the  rule  of  some  practitioners  to  leave  the  pulp 
chamber  open  for  a  few  days  after  the  removal  of  a  dead  pulp. 
This  I  consider  very  bad  practice.  As  has  already  been  men- 
tioned, a  much  more  virulent  infection  may  be  introduced  by 
failure  to  follow  the  most  rigid  asepsis.  These  teeth  may  be 
comfortable  with  such  treatment,  but  it  may  result  in  the 
eventual  loss  of  the  tooth  from  alveolar  abscess.  If  the  most 
careful  technic  is  employed  at  the  first  sitting,  the  number  of 
cases  in  which  inflammation  and  pain  will  develop  will  be  very 
few.  However,  each  patient  should  be  told  to  report  if  the  tooth 
should  become  tender  or  painful.  The  rubber  dam  may  then  be 
placed,  and  the  treatment  removed  and  replaced  at  once  under 
aseptic  precautions.  This  will  give  the  same  relief  as  by  leav- 
ing the  tooth  open,  and  new  infection  is  avoided.  The  danger  of 
periapical  inflammation  can  not  be  positively  eliminated  by  any 
plan  of  treatment. 

Treatment  of  pulp  chambers  which  have  been  narrowed  by 
calcific  deposits. 

When  the  pulp  chamber  is  filled  with  secondary  deposits, 
the  effort  should  be  directed  to  the  removal  of  these,  preserving 
the  outlines  of  the  pulp  chamber.  When  the  pulp  chamber  is 
much  narrowed  by  secondary  dentin  deposited  upon  its  walls, 
the  openings  into  the  canals  should  be  found  before  any  cutting 
is  done,  and  then  the  cutting  carefully  directed  to  straightening 
them.  In  most  instances  this  is  done  best  with  the  barbed 
broach.  All  small  tortuous  canals  should  be  enlarged  and 
straightened  with  the  barbed  broach.  To  do  this,  the  broach 
should  be  passed  into  the  canal  as  far  as  possible  and  withdrawn. 
The  barbs  will  impinge  upon  the  walls  and  cut  away  the  dentin 
from  the  prominent  parts  of  the  crooks  and  straighten  them. 
This  should  be  repeated  again  and  again,  pressing  the  broach 
in  a  direction  during  its  withdrawal  that  will  tend  most  to 
straighten  the  canal.  By  repetitions  of  the  movement,  a  canal 
which  can  be  entered  by  the  smallest  broach  can  soon  be 
enlarged  sufficiently  for  filling.  When  canals  are  so  small  that 
the  smallest  barbed  broach  will  not  enter,  a  fine  smooth  broach, 


Fig.  300. 


Fig.  391. 


Fig.  392. 


Fig.  393. 


Figs.  .390  to  393.     Outliue  dniwings  cxiihiiniiiii  tl iiciiin-,'  of  tlic  pulp  I'linniln-r 

and  canals  in  the  incisor  teeth  when  tliis  is  done  tlirougli  tlie  lingual  surface. 

Fig.  390.  The  opening  to  the  pulp  chamber  from  the  lingual  surface  as  first 
made  with  the  drill. 

Fig.  391.  The  opening  as  modified  by  a  fissure  i)ur.  wiiicli  is  placeil  in  the  drill 
hole  and  inclined  so  as  to  cut  to  the  incisal,  straightening  tiic  aiijiroach  to  the  pulp 
canal. 

Fig.  392.  The  fissure  bur  is  turned  to  the  deeper  portion  and  a  cut  ma<le  lingually, 
straightening  the  ajjproach  of  the  broach  to  the  apic;il  portion  of  the  canal. 

Fig.  393.  Finally  the  incisal  point  or  edge  of  llir  \<\\\\'  ciiandjer  is  made  acces- 
sible by  a  fissure  bur,  or  a  12-5-12  hoe,  as  shown  in  Ihis  liguvc  This  part  of  the 
pulp  chamber  can  then  be  thorougldy  cleaned  and  lilli'd.  (l.-ncnilly  in  tlic  incisor 
teeth  of  young  persons  the  drill  will  strike  tin-  pulp  some  distancr  from  its  incisal 
end.  as  sliown  in  Figure  390,  and  any  neglect  to  clcnn  ;ind  fill  this  poriion  is  certain 
to  result  in  a  discoloration  of  the  crown  of  the  tooth  sooner  or  later. 


Fig.  394. 


Pig.  395. 


Fig.  396. 


Figs.  394,  39.5,  396.  Three  radiographs  of  the  same  upper  cuspid  wi\h  a  wire 
in  the  canal,  to  show  the  difference  in  the  shadow-length  of  the  root,  as  a  result 
of  the  direction  of  the  rays  and  the  position  of  the  film.  With  the  length  of  the  wire 
known,  the  length  of  the  root  can  be  definitely  determined  from  the  shadowdcngth 
on  the  film,  no  matter  what  the  distortion. 


TREATMENT    OF    THE    DENTAL   PULP.  325 

which  has  been  roughened  with  a  file,  may  be  used  for  the  first 
trimming.* 

Generally,  partial  occlusions  of  canals  are  confined  to  or 
near  their  pulpal  ends,  and  when  these  have  been  enlarged,  the 
broach  will  pass  to  the  apex.  In  elderly  people  certain  canals 
are  often  too  small  for  successful  cleaning  and  filling.  In  cases 
in  which  there  has  been  much  abrasion,  the  pulp  chambers  and 
the  pulpal  ends  of  the  root  canals  are  apt  to  be  much  narrowed 
by  secondary  dentin.  This  applies  to  all  of  the  teeth  in  the 
mouth  —  i.  e.,  to  any  that  have  from  any  cause,  not  been  worn 
away,  the  same  as  those  which  are  worn. 

Removal  of  calcifications  from  root  canals.  If  there  are 
many  fusiform  calcifications  in  the  root  canals  they  will  often 
interfere  seriously  with  passing  a  broach  to,  or  nearly  to  the 
apical  foramen.  One,  who  has  had  experience,  will  recognize 
by  the  sense  of  touch  that  the  difficulty  is  due  to  this  kind  of  calci- 
fication. Then  the  object  should  be  to  force  the  broach  as  far 
as  possible  alongside  of  such  calcifications,  and  in  withdrawing 
it,  obtain  room  to  thrust  the  broach  still  further.  Finally,  if 
the  approach  to  the  canal  has  been  well  opened,  the  broach  will 
catch  the  mass  in  such  a  way  as  to  withdraw  it  as  a  whole,  clean- 
ing the  canal  very  effectively.  Occasionally,  however,  the  whole 
mass  will  have  to  be  broken,  by  continuous  probing,  cutting  out 
a  little  at  a  time  until  the  canal  is  cleaned  of  its  contents.  This 
is  tedious.  Often  there  is  a  shoulder  left  near  the  opening  of 
the  canal.  If  this  is  cut  away,  the  entire  contents  of  the  canal 
may  come  away  easily.  This  is  an  operation  requiring  expe- 
rience and  a  great  deal  of  patience  for  the  best  success. 

Removal  of  previous  root  canal  fillings. 

A  number  of  cases  present  with  inflammation  of  the  peri- 
apical tissues,  in  which  the  root  canal  has  been  previously  treated 
and  a  root  filling  made.  It  may  be  that  all  of  the  pulp  tissue 
was  not  removed,  and  the  portion  remaining  became  infected; 
or  the  root  may  not  have  been  filled  to  the  apex  and  serum  col- 
lected in  the  open  space  and  became  infected;  or  the  root  filling 
may  have  been  pushed  through  beyond  the  apex,  causing  an 
inflammation ;    or    some    of    the    peridental    membrane    about 

*  To  roughen  a  broach  with  a  file,  one  should  use  a  flat  file  cut  only  one  way  — 
not  cross  cut.  The  broach  should  be  laid  on  a  piece  of  moderately  hard  wood  and  the 
file  carried  diagonally  across  it,  the  broach  being  permitted  to  roll  under  the  file,  while 
a  single  motion  is  made  with  heavy  pressure.  The  file  cuts  will  tend  to  cut  barbs  on 
the  broach  in  a  spiral  form  around  it.  Tf  this  is  properly  done,  such  a  l)roach  will 
cut  the  dentin  quite  readily. 

8b 


326  SPECIAL   DENTAL   PATHOLOGY. 

the  apex  may  have  been  destroyed  before  the  dead  pulp  was 
removed ;  or  tliis  tissue  may  have  been  injured  by  medicaments 
sealed  in  the  canal.  There  may  be  an  apical  pericementitis,  or 
an  acute  or  chronic  alveolar  abscess.  The  treatment  of  these 
will  be  considered  later.  We  are  concerned  now  only  with  the 
technic  of  the  treatment  of  the  root  canal. 

A  radiograph  will  usually  be  of  great  value  in  determining 
the  difficulties  to  be  encountered  and  the  proper  course  of  pro- 
cedure. If  it  is  decided  to  attempt  to  remove  the  previous  root 
canal  filling,  proper  access  to  the  canal,  or  canals,  must  be  had, 
the  same  as  though  the  pulp  were  to  be  removed.  If  the  root 
filling  has  been  reasonably  well  made  it  will  often  be  impossible 
to  remove  it.  Supposing  the  root  filling  to  have  been  made  of 
gutta-percha,  a  first  effort  should  be  made  by  heating  a  root 
canal  plugger  and  passing  it  into  the  gutta-percha.  Some  of  it 
can  usually  be  removed  in  this  way,  and  a  number  of  efforts 
may  remove  a  fair  portion.  The  gutta-percha  may  be  softened 
beyond  the  point  reached  by  the  end  of  the  plugger,  in  which 
case  a  barbed  broach  or  a  twisted  broach  may  bring  away  the 
remainder.  If  these  fail,  chloroform  may  be  sealed  in  the  canal 
for  twenty-four  hours,  or  eucalyptol  may  be  sealed  in  for  several 
days,  to  soften  the  gutta-percha.  It  may  then  be  possible  to 
remove  it  with  a  broach.  The  removal  of  a  root  filling  will  often 
severely  tax  the  patience  of  the  operator,  and  the  most  pains- 
taking and  persistent  efforts  may  not  be  successful.  One  rule 
should  be  followed,  viz.,  no  instrument  in  the  engine  should  be 
used  in  the  effort  to  reach  the  apex  of  a  root,  on  account  of  the 
danger  of  cutting  through  the  side  of  the  root,  an  accident  which 
practically  always  results  in  the  loss  of  the  tooth. 

Filling  Root  Canals. 

When  it  is  decided  that  the  conditions  are  right  for  filling 
the  root  canal,  or  canals,  of  a  tooth,  the  rubber  dam  must  be 
placed  and  the  included  region  disinfected.  Then  if  a  treatment 
has  been  in  the  canal,  the  gutta-percha  filling  and  the  dressing 
should  be  removed  and  a  critical  examination  made  as  to  its  con- 
dition.    One  principal  point  is  that  the  canal  should  be  dry. 

Size  of  foeamen  and  length  of  canal.  The  size  of  the 
apical  foramen  should  be  ascertained  by  trying  several  sizes  of 
root  canal  pluggers  in  the  canal,  first  sterilizing  each  in  phenol 
and  alcohol.  Those  that  are  smaller  than  the  foramen  will  pass 
through  and  will  be  felt  by  the  patient.  By  beginning  with  a 
large  point,  and  trying  smaller  points  in  graded  sizes,  one  will 


TREATMENT   OF   THE   DENTAL   PULP.  327 

be  found  that  will  just  pass  through  the  apical  foramen.  The 
length  of  the  root  may  be  ascertained  by  sticking  the  point  of  a 
smooth  broach  through  a  little  piece  of  rubber  dam  and  holding 
the  piece  of  rubber  even  with  the  incisal  end,  occlusal  surface,  or 
any  convenient  landmark  on  the  tooth,  while  the  broach  is  passed 
to  the  apical  foramen  and  is  felt  by  the  patient.  When  the 
broach  is  withdrawn,  the  distance  from  the  rubber  to  the  point 
will  be  the  length  of  the  tooth.  In  large  canals  a  broach  with  a 
very  small  hook  on  the  end  may  be  passed  through  the  foramen 
and  will  catch  on  the  end  of  the  root,  thus  giving  the  length. 

The  size  of  the  foramen  and  the  length  of  the  root  may  be 
very  accurately  determined  with  the  X-ray,  For  this  purpose, 
several  sizes  of  brass  wire  should  be  kept  on  hand,  and  in  each 
case  the  largest  size  which  may  be  passed  through  the  apex 
should  be  used.  A  piece  of  this  wire  should  be  passed  into  the 
canal  until  the  patient  feels  it ;  the  other  end  should  then  be  bent 
over  the  edge  of  the  cavity  or  on  the  floor  of  the  pulp  chamber, 
the  cavity  sealed  with  gutta-percha  and  a  radiograph  made. 
The  radiograph  will  seldom  show  the  real  length  of  the  root,  but 
its  actual  length  may  be  determined  by  measuring  the  wire  and 
making  the  necessary  correction  in  case  the  wire  has  been  passed 
beyond  the  apex  or  not  quite  to  it.  Figures  394,  395  and  396  are 
reproductions  of  three  radiographs  of  the  same  upper  cuspid 
with  a  wire  in  the  canal,  showing  variations  in  the  projection  of 
the  root  shadow  on  the  film.  For  example,  if  the  wire  is  14  mm. 
long,  and  in  the  radiograph  it  measures  16  mm.  while  the  root 
in  the  radiograph  measures  20  mm.,  the  actual  length  of  the  root 
would  be  17.5  mm.,  as  its  length  would  be  exaggerated  in  the 
radiograph  in  the  same  proportion  as  the  wire. 

Technic  for  large  canals.  The  canal  should  be  flooded 
with  eucalyptol  or  oil  of  cajuput,  liberally  applied  upon  a  wisp 
of  cotton  wrapped  upon  a  broach,  and  the  excess  dried  out  with 
a  fresh  wisp  of  cotton.  A  gutta-percha  cone  should  be  selected 
and  about  two  or  three  millimeters  should  be  cut  off  to  use. 
This  piece  should  be  of  a  size  which,  from  the  information  gained 
of  the  size  of  the  apical  end  of  the  canal,  will  be  sufficient  to  fully 
fill  the  opening  and  not  be  forced  through  it.  A  root  canal 
plugger  of  proper  size,  tested  by  passing  it  into  the  canal  as  far 
as  it  will  need  to  go,  should  have  the  end  warmed  in  the  flame, 
and  while  holding  the  piece  of  gutta-percha  cone  in  the  thumb 
and  finger  of  the  left  hand,  its  point  should  l)o  brought  quickly  in 
contact  with  the  large  end  of  the  cone  and  licld  a  moment  or  until 
the  gutta-percha  has  stuck  to  the  end  of  the  instrument.     After 


328  SPECIAL   DENTAL   PATHOLOGY. 

the  giitta-percha  has  had  time  to  become  cold  and  hard,  it  should 
be  immersed  in  i)henol  and  alcohol  to  render  it  sterile,  then  it 
should  be  dipped  into  eucalyptol,  which  will  soften  the  surface 
of  the  gutta-percha  slightly.  It  should  then  be  conveyed  to  the 
root  canal  and  carried  carefully  and  firmly  into  its  apical  end. 
On  withdrawing  the  root  plugger,  the  gutta-percha  cone  will 
remain,  closing  the  apical  end  of  the  root.  This  procedure 
should  be  followed  with  other  bits  of  gutta-percha  cones,  cut 
from  larger  parts  of  the  cones  as  the  canal  is  filled  to  its  larger 
portion,  using  larger  root  canal  pluggers.  After  the  first  two  or 
three  pieces,  the  subsequent  ones  may  be  slightly  softened  by 
passing  them  quickly  over  a  flame  and  directly  into  the  canal. 
This  should  be  continued  until  the  canal  is  full. 

Rationale  of  this  proceduee.  By  flooding  the  root  canal 
with  eucalyptol  or  oil  of  cajuput,  the  moisture  is  effectually 
removed.  The  oils  have  a  greater  affinity,  or  attraction,  for  the 
dentin  than  has  the  moisture  and  therefore  displace  it.  In  prac- 
tice this  is  a  much  better  method  than  drying  with  hot  air  or  hot 
instruments.  The  diying  is  done  much  more  perfectly  and  more 
easily.  In  this  operation  the  cotton  wrapped  on  the  broach  should 
never  be  in  such  quantity  as  to  force  the  oil  through  the  apical 
foramen.  Any  such  action  should  be  strictly  avoided.  These 
oils  dissolve  gutta-percha  slightly,  and  the  little  oil  remaining 
serves  to  stick  the  gutta-percha  firmly  to  the  walls  of  the  canal. 
By  putting  in  the  gutta-percha  in  small  pieces,  an  opportunity 
is  given  to  pack  every  portion  of  the  canal  and  all  of  its  irregu- 
larities full. 

In  filling  root  canals  that  are  ver^^  large  at  the  apical  end, 
as  in  young  persons,  care  must  be  exercised  that  the  first  cone 
selected  is  not  so  small  that  it  could  be  forced  through  into  the 
apical  space. 

Technic  foe  small  canals.  In  very  small  canals,  in  which 
there  is  much  doubt  of  being  able  to  reach  the  apical  end, 
chloro-percha  (gutta-y)orcha  dissolved  in  chloroform)  should  be 
pumped  into  them,  filling  them  as  completely  as  possible,  and 
then  a  small  solid  cone  forced  in.  This  pumping  in  of  chloro- 
percha  is  done  by  wray:)ping  three  or  four  fibers  of  cotton  firmly 
on  a  small  broach,  dipinng  this  in  the  chloro-percha  and  convey- 
ing it  into  the  canal  and  pumping  it  back  and  forth,  repeating  the 
operation  until  the  canal  seems  to  be  well  filled.  A  root  canal 
plugger  of  suitable  size  may  then  be  thrust  into  it  and  some  of 
the  chloro-percha  forced  from  the  pulpal  end.  A  suitable  gutta- 
percha cone,  previously  prepared,  may  be  thrust  as  far  into  the 


•17  Weeks 
Fig.  397. 


Fig.  398. 


Fig.  397.  J)iaffrain  of  the  ilecidiious  teeth,  considerably  eiilar^^eii,  re]>r(^seiitinpj 
the  prof^ress  of  their  calcification.  0,  placed  upon  the  individual  teeth  represents  the 
progress  of  calcification  at  birth.  The  figures  1,  2  and  3  represent,  in  years,  the 
progress  of  the  calcification  of  each  tooth.  The  intention  is  to  represent  averages. 
It  must  be  understood  that  considerable  variations  will  be  found. 

Fig.  398.  Diagram  of  the  deciduous  teeth,  considerably  enlarged,  repres<>ntiiig 
tho  absorption  of  the  roots.  The  figure  jtlaced  over  eacli  tooth  rejiresents,  in  years, 
the  average  time  of  the  lieginning  of  the  absorption  of  its  roots.  The  figures  placed 
upon  the  roots  of  the  teeth  represent,  in  years,  the  ]irogress  of  the  absoriitiim  of  the 
roots  of  tho  several  teeth.  Considerable  variation  from  the  general  average,  and 
also  in  the  order  of  progress,  must  be  expected.  Not  infrequently  the  absorption  of 
the  root  of  the  second  molar  is  completed  before  that  of  the  first. 


Fig.  399. 


Fig.  400. 


Fig.  401. 


Fig.  399.  Eadiograph  of  upper  front  tooth  of  hoy  seven  years  old.  The  riglit 
deciduous  central  incisor  was  abscessed  and  absorption  of  the  root  had  not  occurred, 
while  the  roots  of  the  other  three  deciduous  incisors  are  being  absorbed.  The  shadow 
of  the  root  of  the  right  deciduous  central  incisor  may  be  seen  overlapping  that  of  the 
permanent  central  crown. 

Fig.  400.  Radiograph  of  lower  jaw,  boy  twelve  years  old,  showing  deciduous 
second  molar  with  roots  about  bicuspid  crown. 

Fig.  401.  Two  deciduous  molars,  which  brought  the  bicuspid  germs  with  them 
when  they  were  extracted.  Quite  a  few  of  the  missing  bicuspids  have  been  lost  in 
this  way.     Specimens  from  Northwestern  University  Dental  Museum. 


TREATMENT    OF    THE    DENTAL   PULP.  329 

canal  as  possible.  Such  canals  may  not  always  be  perfectly 
filled  by  this  plan,  nor  by  any  other,  but  in  each  case  the  best 
effort  should  be  made. 

In  some  of  the  smaller  canals,  the  regular  root-canal  plug- 
gers  will  be  too  large,  and  a  broach  of  suitable  size  may  be  used 
instead.  In  the  daily  use  of  broaches  a  large  number  of  these 
may  be  collected  with  which  to  handle  root  dressings  and  for 
filling  canals  that  are  too  small  for  the  ordinary  root  pluggers. 

Canals  grouped  into  two  classes.  While  it  is  impractica- 
ble to  definitely  group  the  canals  of  the  various  teeth  into  two 
classes,  it  may  be  said  that  chloro-percha  will  generally  be 
needed  in  the  upper  laterals,  first  bicuspids  and  buccal  canals  of 
molars,  also  in  the  lower  incisors  and  mesial  canals  of  molars. 
Chloro-percha  should  generally  not  be  necessary  in  the  upper 
centrals,  cuspids,  second  bicuspids  and  lingual  canals  of  molars ; 
nor  in  the  lower  cuspids,  bicuspids  and  distal  canals  of  molars. 
There  will  be  many  exceptions  owing  to  variations  in  the  sizes 
of  canals,  formations  of  secondary  dentin,  the  age  of  the 
patient,  etc. 

The  pulp  chamber  should  not  be  filled  with  gutta-percha. 
This  material  is  much  too  soft  to  serve  as  a  seat  for  a  metallic 
filling.  In  any  case  in  which  it  is  not  desirable  to  fill  the  pulp 
chamber  with  the  material  with  which  the  cavity  is  to  be  filled, 
oxyphosphate  of  zinc  should  be  used. 

To  prevent  evaporation  of  chloro-percha.  The  evapora- 
tion of  chloroform  from  chloro-percha  may  be  prevented,  in 
large  measure,  by  keeping  the  bottle  containing  the  solution 
upside  down.  By  standing  the  bottle  on  its  cork,  a  little  of  the 
chloro-percha  will  pass  in  between  the  cork  and  the  opening  of 
the  bottle,  and  as  the  chloroform  evaporates  from  this  portion, 
the  remaining  gutta-percha  will  seal  the  opening  so  that  no  more 
chloroform  may  evaporate.  The  contents  of  the  bottle  will 
therefore  remain  in  a  plastic  state,  ready  for  use  at  any  time. 

Horns  of  pulp  chambers.  Attention  to  the  horns  of  pulp 
chambers  is  most  urgently  demanded  in  the  incisors,  cuspids  and 
bicuspids.  In  incisors  particularly,  exposure  of  the  pulp, 
whether  made  primarily  by  caries  or  by  cutting  into  them,  are 
usually  at  some  distance  from  the  incisal  end  of  the  pulp,  leaving 
an  end  protruding  into  the  incisal  end  of  the  crown  of  the  tooth. 
This  has  been  especially  noted  and  illustrated  in  Figures  390, 
391,  392  and  393.  It  is  also  true  that  in  cutting  into  the  pulp 
chambers  of  bicuspids,  one  is  liable  to  leave  one  or  both  of  the 
horns  of  the  pulp  chamber  uncleaned  and  unfilled.     Before  filling 


330  SPECIAL   DENTAL   PATHOLOGY. 

the  cavity,  this  must  be  looked  for  and  these  openings  so  exposed 
that  every  part  of  them  may  he  cleaned  and  filled.  Any  neglect 
in  this  will  result  in  discoloration  of  the  tooth  by  decomposition 
of  the  debris,  left  in  this  neglected  portion  of  the  pulp  chamber. 
In  cuspids  and  bicuspids,  the  horns  of  the  pulp  are  often  long 
and  slender  and  penetrate  far  toward  the  ends  of  the  cusps. 
Unless  these  are  thought  of  and  especially  looked  for  and  cut 
out,  so  that  they  may  be  perfectly  filled,  discoloration  of  the 
tooth  in  some  degree  is  sure  to  occur.  This  may  occur  in  the 
molars  as  well,  especially  in  young  persons  whose  teeth  have 
long  cusps.  Nothing  of  this  kind  should  escape  notice  and  cor- 
rection. A  study  of  these  points  in  practice  will  soon  bring  such 
a  knowledge  of  the  positions  of  the  horns  of  the  pulp  that  their 
exposure  will  be  but  a  matter  of  a  few  strokes  of  an  instrument 
at  the  right  points. 

Tkeatment  of  Pulps  of  the  Deciduous  Teeth. 

There  is  perhaps  nothing  that  can  be  considered  as  more 
important  in  the  general  management  of  a  practice  than  the 
proper  attention  to  the  deciduous  teeth  to  prevent  exposures  of 
pulps  in  them  by  caries.  These  little  teeth  often  begin  to  decay 
verj^  early,  and  constant  watchfulness,  particularly  for  decays 
upon  the  proximal  surfaces,  is  of  paramount  importance.  If 
decays  expose  the  pulps,  it  is  difficult  for  the  dentist  to  handle 
these  teeth  successfully  afterward. 

The  exposure  may  come  at  a  time  when  it  is  impossible  to 
make  a  good  root  filling.  The  root  may  not  be  fully  formed  or 
possibly  absorption  may  have  begun,  so  that  the  end  of  the  canal 
can  not  be  properly  filled.  The  period  during  which  the  roots 
of  the  deciduous  teeth  are  full  length  is  comparatively  short,  and 
this  is  the  only  time  when  really  good  root  fillings  may  be  made. 

Time  of  complete  calcification  and  beginning  absorption 
OF  roots.  The  accompanying  illustrations  give  about  the  aver- 
age progress  of  calcification  of  the  deciduous  teeth,  also  the  aver- 
age progress  of  absorption  of  the  roots.  There  are  numerous 
variations  from  these.  (See  Figures  397  and  398.)  It  will  be 
noticed  that  the  central  and  lateral  incisors  are  both  fully  calci- 
fied during  the  second  year,  and  that  absorption  of  the  root  of 
the  central  begins  about  the  fourth  year,  that  of  the  lateral  a 
year  later.  The  roots  of  the  cuspid  and  both  molars  are  fully 
calcified  by  the  end  of  the  third  year,  while  absorption  of  the 
root  of  the  cuspid  does  not  begin  until  the  ninth  year,  the  first 
molar  at  seven  and  the  second  molar  at  eight.     As  a  general 


TREATMENT    OF    THE    DENTAL   PULP.  331 

statement,  there  is  the  opportunity  to  properly  fill  the  root  of  the 
central  incisor  when  the  child  is  between  the  ages  of  two  and 
four,  the  root  of  the  lateral  incisor  between  the  ages  of  two  and 
five,  of  the  cuspid  between  three  and  nine,  the  first  molar  between 
three  and  seven,  the  second  molar  between  three  and  eight. 

Serious  results  of  exposures  of  pulps  of  deciduous  teeth. 
It  often  happens  that  exposure  of  the  pulp  of  a  deciduous 
tooth  will  mean  the  premature  loss  of  the  tooth.  This  may  lead 
to  serious  consequences  by  causing  irregularities  in  the  eruption 
of  the  permanent  teeth.  If,  for  example,  the  second  deciduous 
molar  is  lost  in  this  way,  there  is  nothing  to  prevent  the  first 
permanent  molar  from  moving  forward  so  that  it  laps  over  the 
space  where  the  second  bicuspid  should  come  through.  This 
condition,  or  some  similar  irregularity,  is  liable  to  occur  as  a 
result  of  the  early  extraction  of  any  of  the  deciduous  molars. 

One  case  that  came  under  my  observation  soon  after  I  began 
practice  has  come  to  my  mind  many  times  since.  A  girl  between 
thirteen  and  fourteen  years  old  (small  for  her  age),  called  on 
me,  saying  that  there  was  something  about  her  lower  jaw  that 
annoyed  her,  without  there  being  any  real  pain.  I  examined  the 
case  and  noticed  that  neither  lower  second  bicuspid  was  in  posi- 
tion, and  that  both  first  bicuspids  were  in  their  proper  places, 
with  the  first  molars  inclined  very  far  forward,  occupying  fully 
two-thirds  of  the  spaces  where  the  second  bicuspids  should  be. 
They  were  one  cusp  too  far  mesially  in  relation  to  the  upper 
teeth.  The  lower  second  deciduous  molars  had  been  extracted 
because  of  alveolar  abscess,  according  to  the  history  she  gave. 
I  passed  a  sharp,  slender  instrument  through  the  gum  tissue  on 
one  side  and  located  the  second  bicuspid.  I  also  made  out  that 
the  buccal  cusp  of  the  tooth  was  through  the  bone. 

When  she  returned,  I  had  determined  to  restore  the  space 
for  the  second  bicuspids,  which  I  did,  taking  one  side  at  a  time, 
by  placing  pieces  of  hickory  wood,  with  the  grain  in  the  bucco- 
lingual  direction,  between  the  first  bicuspid  and  the  first  molar. 
The  wood  was  previously  compressed  in  the  vise  and  trimmed 
to  fit  accurately.  Larger  pieces  were  used  as  the  space  was 
enlarged.  Then  an  appliance  was  made  to  hold  these  teeth  apart 
until  the  second  bicuspid  erupted,  which  it  did  within  a  few 
weeks. 

This  little  girl  had  had  toothache  and  the  pulps  had  died  as 
a  result  of  neglected  decays ;  she  had  gone  through  the  ordeal  of 
alveolar  abscess  and  finally  tlio  al)scessed  teeth  were  extracted. 
As  a  result  the  first  permanent  molars  were  tit)ped  forward,  and 


332  SPECIAL    DENTAL    PATHOLOGY. 

the  second  bicuspids  were  impacted,  and  if  the  condition  had  not 
been  corrected,  the  malocclusion  would  probablj^  have  led  to 
other  difficulties  later  in  life.  Many  such  cases  even  to-day  are 
passing  without  correction.  If  there  had  been  sufficient  watch- 
fulness as  to  decay  of  these  deciduous  teeth,  the  cavities  would 
have  been  filled  early  enough  to  preserve  the  teeth  until  the 
proper  time  for  shedding. 

The  object  of  this  recital  is  not  to  discuss  the  treatment  of 
such  cases,  but  to  impress  the  fact  that  such  things  can  be  pre- 
vented by  very  simple  means  if  the  decays  are  discovered  before 
the  vitality  of  the  pulp  is  endangered.  In  this  it  should  be 
remembered  that  the  pulps  of  the  deciduous  teeth  are  larger  in 
proportion  to  the  size  of  the  teeth  than  in  the  permanent  teeth, 
and  the  wall  of  dentin  is  correspondingly  thinner,  so  that  a 
depth  of  decay  that  would  not  be  dangerous  in  a  permanent  tooth 
might  be  decidedly  dangerous  in  a  deciduous  tooth.  Therefore, 
the  watchfulness  must  be  closer  and  more  exacting  than  in  the 
permanent  teeth.  Every  child  should  be  required  to  visit  the 
dentist  for  examination  at  regular  intervals.  For  most  children 
these  examinations  should  be  not  more  than  three  months  apart. 

When  pulps  of  deciduous  teeth  are  exposed  by  caries,  they 
usually  die  within  a  short  time.  A  pulp  may  die  and  an  alveolar 
abscess  may  develop  and  pass  into  the  chronic  form  with  a  sinus 
discharging  through  the  gum,  without  much  complaint  from  the 
child.  In  many  of  the  cases,  however,  there  is  great  pain  accom- 
panied by  fever  during  the  development  of  an  acute  alveolar 
abscess. 

Occasionally,  deciduous  molars  will  be  retained  beyond  the 
normal  time  for  shedding.  If,  for  any  reason,  these  teeth  are  to 
be  extracted,  it  should  be  remembered  that  the  germ  of  the  form- 
ing bicuspid  may  be  locked  between  the  roots  of  the  deciduous 
molar,  and  will  be  in  danger  of  being  extracted  with  it.  (See 
Figures  400,  401.) 

Technic  same  as  for  permanent  teeth.  If  a  case  presents 
with  the  pulp  exposed,  but  not  yet  dead,  it  may  be  treated  along 
the  same  general  lines  as  mentioned  for  the  permanent  teeth. 
Arsenic  should  be  left  in  the  deciduous  teeth  for  a  shorter  time, 
usually  about  twenty-four  hours.  Oil  of  cloves  may  be  sealed 
in  for  a  week,  when  the  pulp  will  usually  be  found  to  be  dead,  or 
so  nearly  so  that  it  may  be  removed  without  causing  much  pain. 

The  subsequent  treatment,  including  the  root  filling,  should 
be  the  same  as  for  permanent  teeth,  for  unless  every  detail  is 


TREATMENT   OF   THE   DENTAL   PULP.  333 

properly  carried  out  abscesses  are  likely  to  occur.  The  rubber 
dam  should  be  in  place  and  every  precaution  should  be  taken  as 
to  asepsis.  In  carrying  out  the  treatment  of  these  cases,  every- 
thing should  be  prepared  in  advance  so  that  the  shortest  possible 
time  will  be  occupied  in  the  operations.  The  dentist  should  have 
in  mind  distinctly  that  he  is  dealing  with  a  child  and  often  can 
not  keep  the  child  in  the  chair  as  long  as  may  be  necessary  to  do 
all  that  he  might  wish  at  one  time.  Therefore,  he  must  make 
provision  for  cutting  short  the  treatment  before  it  is  completed, 
placing  quickly  a  dressing  and  a  temporary  filling,  and  dis- 
missing the  child  until  a  subsequent  day. 

Chronic  abscesses.  Chronic  abscesses  from  deciduous  teeth 
will  often  heal,  following  proper  pulp  treatment  and  root  filling. 
In  cases  in  which  these  abscesses  can  not  be  cured,  the  teeth 
should  be  extracted.  It  should  be  remembered  that  absor^^tion 
of  the  root  of  a  deciduous  tooth  does  not  occur  if  there  is  a 
chronic  abscess,  the  activity  of  the  absorption  cells  being  pre- 
vented loy  the  presence  of  the  suppurative  focus.  Thus  irregu- 
larities of  the  permanent  teeth  may  be  caused  by  the  failure  of 
absorption  of  the  roots  of  abscessed  deciduous  teeth. 

The  accompanying  illustration,  Figure  399,  shows  one  decid- 
uous upper  incisor,  the  root  of  which  has  not  been  absorbed 
because  of  an  abscess,  while  the  roots  of  the  other  three  incisors 
are  almost  entirely  absorbed. 

Better  care  desirable.  I  have  come  to  feel  that  tlie  treat- 
ment of  these  cases  has  not  been  as  careful  and  painstaking  as 
it  should  be.  Most  dentists  seem  to  have  carried  the  teeth  along 
with  the  least  discomfort  possible,  not  succeeding  in  making 
their  treatment  effective.  Children  are  so  difficult  to  handle  that 
proper  treatments  are  not  attempted.  Abscessed  teeth  are 
neglected  so  long  as  the  child  is  free  from  pain  ;  or  if  the  child  is 
suffering,  nothing  further  than  is  necessary  for  temporary  relief 
is  undertaken.  Every  dentist  should  exert  himself  to  carry 
through  treatments  of  the  deciduous  teeth  to  a  really  successful 
result. 

Another  point  of  still  greater  importance  perhaps  is  the 
awakening  of  a  feeling  among  the  laity  and  especially  among  the 
parents  that  children  should  visit  the  dentist  often,  in  order  that 
simple  operations  may  be  done  in  ample  time  to  prevent  the 
development  of  more  serious  conditions.  By  this  plan  the  child 
will  have  less  fear  and  will  come  to  have  confidence  that  the 
serv^ice  of  the  dentist  will  l)e  of  great  benefit.     Children  are  quick 

31 


334  SPECIAL   DENTAL   PATHOLOGY. 

to  appreciate  a  successful  operation.  The  dentist  should  con- 
tinually impress  upon  the  parents  the  necessity  of  care  of  their 
children's  teeth;  correcting  misapprehension  and  giving  infor- 
mation as  to  the  means  of  cleaning  for  the  prevention  of  decay, 
as  far  as  that  is  possil)le.  The  dentist  should  enter  into  close 
relation  with  mothers  and  nurses  upon  these  subjects,  in  order 
that  they  may  work  together  understandingly  for  the  benefit  of 
the  children.  Until  this  is  done  many  children  will  be  brought  to 
the  dentist  for  the  first  time  with  aching  teeth,  with  all  of  their 
sensitiveness  developed,  and  it  will  be  impossible  to  handle  them 
properly. 

Filling  of  deciduous  teeth.  In  the  deciduous  molar  teeth 
decays  in  the  occlusal  surface  often  occur  very  early.  At  the 
first  opportunity  after  the  eruption  of  these  teeth  the  occlusal 
surfaces  should  be  carefully  examined,  and  if  the  pits  and 
fissures  are  deep,  though  not  decayed,  these  should  be  filled  with 
cement  at  once,  without  cutting  cavities.  This  is  best  done  per- 
haps with  oxyphosphate  of  copper  cement,  filling  them  as  full  as 
the  occlusion  will  allow.  Such  fillings  will  require  renewal  from 
time  to  time. 

If  the  child  presents  after  decay  has  occurred,  the  decay 
should  be  very  thoroughly  removed  and  fillings  made.  The  cop- 
per cement  is  being  used  extensively  for  this,  and  is  one  of  the 
most  satisfactory  materials  available.  Care  must  be  taken  to 
remove  every  particle  of  carious  dentin,  otherwise  the  tooth  is 
liable  to  be  discolored.  Fillings  of  base-plate  gutta-percha, 
especially  in  occlusal  cavities,  will  usually  not  last  quite  as  well 
as  those  of  copper  cement.  Amalgam  should  not  be  used  unless 
conditions  are  such  that  the  cavity  may  be  unquestionably  dry. 
If  the  cavity  walls  are  moist  in  the  slightest  degree,  a  recurrence 
of  decay  is  practically  certain  and  this  will  often  progress  to  the 
involvement  of  the  pulp  before  it  receives  attention.  Copper 
cement  or  gutta-percha  do  not  permit  such  a  leakage,  but  are 
gradually  cupped  out  by  wear.  They  should  be  replaced  as 
often  as  may  be  necessary.  Care  should  be  taken  to  maintain 
contacts  between  the  deciduous  molars,  and  between  the  second 
deciduous  molar  and  the  first  permanent  molar,  to  prevent  the 
impaction  of  food. 

The  deciduous  incisor  teeth  begin  to  separate  as  the  arch 
expands  with  the  growth  of  the  permanent  teeth.  Usually  the 
movement  begins  during  the  third  year,  after  which  fillings  may 
be  made  in  proximal  surfaces  of  these  teeth  without  the  neces- 


TREATMENT    OF    THE    DENTAL   PULP.  335 

sity  of  restoring  contacts.  In  my  work  on  Operative  Dentistiy 
I  have  called  attention  to  the  plan  of  cutting  away  slight  proxi- 
mal decays  of  these  teeth  which  have  occurred  before  the  teeth 
have  begun  to  separate.  In  this  way  further  decay  may  be  pre- 
vented and  the  necessity  of  placing  fillings  avoided. 

These  few  suggestions  relative  to  the  management  of  caries 
in  the  deciduous  teeth  are  made  for  the  especial  purpose  of 
emphasizing  the  importance  of  the  care  which  is  necessary  to 
protect  their  pulps. 


336  SPECIAL   DENTAL   PATHOLOGY. 


ACUTE  ALVEOLAR  ABSCESS 

ILLUSTRATIONS:    FIGURES  402-429. 

AN  abscess  is  a  collection  of  pus  in  a  cavity  formed  within 
.  some  tissue  or  organ  of  the  body  as  a  result  of  suppuration. 
An  alveolar  abscess  is  so  named  because  it  occurs  within  the  bone 
which  forms  the  alveolar  process. 

I  have  previously  described  the  lateral  alveolar  abscess, 
which  also  involves  the  peridental  membrane  and  the  bone  of  the 
alveolar  process.  Such  an  abscess  occurs  as  a  result  of  an 
inflammation  which  originates  at  the  gingival  line  of  the  tooth 
and  the  pulp  may  be  alive  or  dead ;  there  is  no  relation  between 
the  condition  of  the  pulp  and  the  formation  of  a  lateral  abscess. 
The  occurrence  of  true  alveolar  abscess  is  always  subsequent  to 
the  death  of  the  pulp. 

It  might  seem  that  a  modifying  adjective  should  be  used  to 
more  clearly  designate  a  true  alveolar  abscess.*  The  term  alveo- 
lar abscess  has  been  so  generally  used  to  designate  this  condition 
that  I  am  inclined  to  favor  its  continuance,  and  to  make  the 
differentiation  of  the  other  abscesses  of  the  investing  tissues  of 
the  teeth  by  using  the  qualifying  tenns  in  designating  the  posi- 
tions in  which  they  occur.  These  are  the  gingival  abscess,  septal 
abscess  and  lateral  alveolar  abscess.  In  this  writing  we  will 
define  alveolar  abscess  as  a  collection  of  pus  in  the  periapical 
tissues  due  to  infection  from  the  root  canal  of  a  tooth. 

Etiology. 

As  a  sequel  to  the  destruction  of  the  pulp  by  hyperemia  or 
inflammation,  no  matter  how  these  are  caused,  the  area  of  peri- 
dental membrane  around  the  apex  of  the  root  may  become 
involved  in  inflammation.  This  occurs  only  after  the  pulp  in  the 
tooth  is  dead  from  one  of  the  causes  mentioned.  Following  the 
death  of  the  pulp,  there  are  three  principal  exciting  causes  of 
periapical  inflammation:  (1)  The  escape  through  the  apical 
foramen  of  saprophitic  organisms,  or  the  poisonous  products  of 

*  Dr.  Thomas  L.  Gilmer,  in  a  paper  on  Alveolar  Abscess,  in  the  Dental  Review, 
Vol.  28,  1914,  p.  427,  has  used  the  term  typical  alveolar  abscess  to  describe  those 
abscesses  following  the  death  of  the  pulp,  and  atypical  alveolar  abscess  as  applying  to 
those  which  occur  from  infections  of  the  peridental  membrane  not  due  to  the  death 
of  the  pulp. 


ACUTE  ALVEOLAE  ABSCESS.  337 

putrefactive  decomposition;  (2)  the  escape  of  pyogenic  organ- 
isms or  the  products  of  suppuration  of  the  pulp ;  (3)  the  passage 
of  certain  medicaments  placed  in  the  root  canal  in  treatment. 
The  affection  is  not  materially  different  because  of  the  different 
conditions  under  which  the  pulp  may  have  died,  but  is  perhaps 
more  rapid  in  its  development  in  the  cases  in  which  the  pulp  has 
died  from  suppuration,  for  in  such  cases  the  apical  tissues  are 
infected  directly  by  the  material  passing  from  the  pulp  into  the 
apical  space. 

Pathological  changes. 

Apical  pericementitis  and  pus  formation.  The  first  in- 
volvement of  the  periapical  tissues  is  an  apical  pericementitis ; 
when  such  an  inflammation  progresses  to  the  stage  of  pus  forma- 
tion, it  becomes  alveolar  abscess.  Most  cases  progress  rapidly 
to  pus  formation,  although  occasional  cases  present  in  which  the 
periapical  inflammation  continues  for  an  indefinite  period  with- 
out suppuration. 

Absorption  of  bone.  An  area  of  bone  forming  the  walls  of 
the  alveolus  of  the  tooth  is  involved  by  the  inflammatory  move- 
ment, and  absorption  of  the  bone  quickly  occurs.  The  fibers  of 
the  peridental  membrane  of  the  region  elongate  as  this  absorp- 
tion takes  place,  extending  out  to  and  perhaps  maintaining  some 
connection  with  the  bone  which  is  being  absorbed,  producing  a 
fan-like  projection  of  comparatively  large  fleshy  fibers  extending 
out  from  the  apical  end  of  the  root  to  the  absorbed  area. 
Between  and  among  these  fibers  is  the  accumulation  of  pus, 
rather  than  in  distinct  abscessed  cavities.  As  the  suppuration 
proceeds,  widening  its  area  in  the  bone,  more  definite  abscessed 
cavity  forms  may  appear. 

The  pus  soon  penetrates  the  dense  plate  of  bone  forming  the 
socket  and  enters  the  cancellous  bone.  (See  P'igure  471.)  The 
latter  is  easily  penetrated  on  account  of  the  many  open  spaces. 
After  a  few  hours  more  time,  the  pus  will  find  a  way  to  the  sur- 
face of  the  bone,  usually  nearest  the  ]>oint  of  the  apex  of  the 
root,  through  some  Haversian  canal  which  offers  an  easier  exit 
than  another  similar  canal  in  the  neighborhood,  and  this  is 
enlarged  by  absorption,  affording  an  exit  of  the  pus  to  the  sur- 
face of  the  bone,  under  the  periosteum.  (See  Figures  402  to  41(), 
also  430  to  432.) 

The  extent  of  the  area  of  the  absorption  of  lione  varies,  and 
may  occur  raj^idly  in  some  cases,  and  slowly  in  others.  I  have 
seen  cases  in  which  all  of  the  changes  llms  I'ai-  desciibcd  occun-ed 


338  SPECIAL   DENTAL   PATHOLOGY. 


Figs.  402  to  407.  A  series  illustrating  acute  and  chronic  alveolar  abscess  occur- 
ring in  the  upper  incisor  region. 

Fig.  402.  Blind  abscess  at  the  root  of  an  upper  central  incisor:  a,  Abscess- 
cavity  in  bone,     b,  Drill-hole  exposing  the  pulp  chamber  for  treatment. 

Fig.  403.  Acute  alveolar  abscess  of  upper  central  incisor  pointing  on  the  gum: 
a,  Abscess  cavity  in  the  bone,  b,  Floor  of  the  nostril,  c,  Lip.  d,  Tooth.  In  this  case 
the  pus  has  penetrated  the  periosteum  without  lifting  it  from  the  bone. 

Fig.  404.  Chronic  alveolar  abscess  at  the  root  of  an  upper  incisor  with  sinus 
discharging  on  the  gum:     a,  Abscess  cavity  in  the  bone,    b,  Mouth  of  sinus,    c,  Lip. 

d,  Tooth. 

Fig.  405.  Acute  alveolar  abscess  in  which  the  pus  has  lifted  the  periosteum  from 
the  bone:     a.  Abscess  cavity  in  the  bone,    b,  Floor  of  the  nostril,    c,  Lip.    d,  Tooth. 

e,  Pus  cavity  beneath  the  periosteum. 

Fig.  406.  Acute  alveolar  abscess,  the  pus  from  which  has  raised  the  periosteum 
from  the  hard  palate:  a,  Very  large  abscess  cavity  in  the  bone,  b,  Pus  cavity 
between  the  periosteum  and  bone,    c,  Lip.    d,  Tooth,    e,  Floor  of  nostril. 

Fig.  407.  Alveolar  abscess  at  the  root  of  an  upper  incisor  discharging  into  the 
nose:  a,  Large  abscess  cavity  in  the  bone,  b,  Mouth  of  sinus  on  the  floor  of  the 
nostril,    c,  Lip.    d,  Tooth. 


Fig.  402. 


Fig.    4U4. 


Fig.  4U5. 


Fig.  406 


Fig.  407. 


*31 


I—: 


Fig.  409. 


Fig.  408. 


Fig.  410. 


ACUTE    ALVEOLAR   ABSCESS.  330 


Figs.  408  td  41L  A  series  illustrating  acute  and  chronic  alveolar  abscess  occur- 
ring in  the  upper  molar  region. 

Fig.  408.  Alveolar  abscess  at  the  root  of  an  upper  molar  discharging  into  tlie 
maxillary  sinus:  a,  Abscess  cavity  in  the  bone,  b,  Mouth  of  sinus  in  the  floor  of 
the  antrum,  c,  Pus  in  the  antral  cavity,  d,  nasal  cavity,  e,  Tooth,  f,  Tissues  of 
cheek. 

Fig.  409.  Acute  alveolar  abscess  from  the  buccal  roots  and  chronic  abscess  from 
the  lingual  root  of  an  upper  molar:  a,  Cavity  of  acute  abscess  in  the  bone,  b,  Pus 
cavity  between  the  bone  and  periosteum,  extending  out  under  the  prominence  of  the 
malar  process,  c,  Tissues  of  cheek,  d,  Tooth,  e,  Maxillary  sinus,  f,  Nasal  cavity. 
g,  Malar  process,     h,  Cavity  of  chronic  abscess  discharging  at  i. 

Fig.  410.  Alveolar  abscess  from  the  buccal  roots  of  an  upper  molar  discharging 
on  the  face:  a,  Abscess  cavity  in  the  bone,  b,  Sinus  opening  on  the  face.  c,. 
Maxillary  sinus,     d,  Nasal  cavity,     e,  Tooth,     f,  Tissues  of  cheek. 

Fig.  411.    Scar  caused  by  alveolar  abscess  discharging  on  the  face. 


81b 


340  SPECIAL    DENTAL    PATHOLOGY. 

over  night,  and  the  face  had  begun  to  swell  in  the  morning,  wliile 
in  others  a  week  elapsed  before  the  bone  was  penetrated. 

If  pus  penetrates  periosteum.  "When  the  pus  has  forced 
an  exit  through  the  bone  and  periosteum  and  enters  the  softer 
tissues,  it  will  usually  form  a  rounded  tumor,  occupying  the 
center  of  an  area  of  infiltration  formed  to  wall  it  oif.  (lenerally 
within  from  one  to  three  or  four  days,  if  the  tissues  are  not 
incised,  the  pus  will  find  an  exit  through  the  soft  tissues  and  be 
discharged.     (See  Figures  403  and  412.) 

If  pus  lifts  periosteum  from  bone.  In  a  minority  of  the 
cases,  the  pus,  on  arriving  at  the  surface  of  the  bone,  meets  with 
conditions  in  which  the  periosteum  is  raised  from  the  bone,  and, 
instead  of  penetrating  the  periosteum,  the  pus  spreads  out  in  a 
broad,  flat  tumor  between  the  bone  and  the  periosteum,  as  distin- 
guished from  the  rounded  tumor  previously  described.  (See 
Figures  405,  406,  409  and  413.) 

This  flat  form  of  tumor  over  the  affected  area  in  alveolar 
abscess  is  very  much  the  more  dangerous  form,  for  it  is  Iial)le 
to  involve  the  bone  in  necrosis.  Necrosis  occurring  from  alveo- 
lar abscess  has  practically  always  been  in  the  cases  in  which 
the  periosteum  was  lifted  from  the  bone  and  this  broad,  flat 
swelling  occurred.  Occasionally,  the  periosteum  will  build  a 
plate  of  new  bone  in  its  new  position.  This  is  called  an  involu- 
crum.  It  may  enclose  the  necrosed  portion.  Figure  463  is  of  a 
boy  who  suffered  from  a  necrosis  of  the  lower  jaw  on  the  left 
side  and  a  large  involucrum  was  so  formed.  His  cheek,  which  is 
apparently  much  swollen,  is  of  the  contour  shown  in  the  illus- 
tration, because  of  the  building  of  the  new  subperiosteal  bone  in 
that  position. 

Variations  in  burrowing  of  pus.  These  cases,  when  left  to 
themselves,  may  present  some  very  peculiar  features.  Pus  may 
become  entangled  among  the  fascia  and  burrow  to  considerable 
distances.  In  the  upper  jaw  it  may  raise  the  periosteum  along 
the  prominences  of  the  malar  process,  or  the  malar  bone  itself, 
and  discharge  upon  the  face.  (See  Figure  411.)  Or  it  may  take 
other  directions  and  discharge  upon  the  face.  Or  again  it  may 
discharge  on  the  gum  similarly  to  the  more  ordinary  form  of 
alveolar  abscess,  or  it  may  tear  up  the  periosteum  to  the  gingiva, 
and  discharge  between  the  gingiva  and  the  tooth.  In  fact,  in 
this  class  of  alveolar  abscess,  location  of  the  discharge  is  very 
variable,  while  in  that  class  which  gives  the  ball-like  form  of 
tumor,  the  location  of  the  discharge  is  almost  universally  upon 


ACUTE    ALVEOLAR    ABSCESS.  341 

the  gum  iu  the  immediate  neigliborliood  of  the  tooth.     (See 
Figures  402  to  416.) 

Distinctions  between  alveolab  abscess  and  abscesses  occurring 
elsewhere. 

Alveolar  abscess  has  characteristics  which  distinguish  it 
prominently  from  all  other  abscesses  occurring  in  the  body.  It 
is  an  abscess  which  has  to  do  especially  with  the  bones  of  the  jaws 
and  is  formed  at  the  ends  of  the  roots  of  tlie  teeth  in  the  depths 
of  the  bony  tissue.  It  is  the  bone  which  seems  to  suffer  most, 
as  is  shown  by  the  pus  cavity  forming  within  the  bone.  The 
peridental  membrane,  which  is  the  real  seat  of  affliction,  is 
usually  only  slightly  involved  in  the  formation  of  the  abscess 
cavity. 

Infection  from  pulp  chamber  or  a  tooth.  The  first  and 
most  important  distinguishing  feature  is  the  fact  that  the  infec- 
tion which  causes  this  abscess  is  derived  from  the  pulp  chamber 
of  a  tooth  after  the  pulp  has  died.  This  infection  will  continue 
so  long  as  the  infected  material  remains  in  the  root  canal.  It  is 
for  this  reason  that  the  abscess,  after  the  acute  stage  has  passed, 
takes  on  a  chronic  character.  Practically  all  acute  abscesses 
become  chronic  if  not  treated,  because  of  this  continual  reinfec- 
tion from  the  contents  of  the  pulp  chamber.  This  is  a  character 
found  in  alveolar  abscess  which  occurs  in  no  other  part  of  the 
body  and  requires  special  technical  treatment.  The  tooth 
affected  must  have  proper  preparation  of  the  root  canal  and 
the  apical  foramen,  and  be  completely  and  perfectly  closed  by  a 
filling  which  is  placed  in  it  for  this  purpose,  before  the  abscess 
can  get  well. 

Cementum,  if  denuded,  maintains  chronicity.  In  some  of 
the  cases,  necrosis  of  bone  occurs  in  connection  with  the  forma- 
tion of  the  abscess,  the  same  as  necrosis  of  bone  occurs  in  other 
regions  in  the  body,  resulting  from  abscesses  in  connection  with 
or  in  the  bone.  There  is  no  particular  difference  in  this  part  of 
the  injury  from  that  which  occurs  in  other  abscesses  involving 
bone.  The  necrosed  bone  is  separated  from  the  living  bone  by 
absorption,  it  loosens,  and  finally  the  se(iuestrum  may  l)c  removed. 
As  in  abscesses  in  the  bone  elsewhere,  it  is  required  that  every 
particle  of  necrosed  bone  be  removed  before  the  abscess  can  got 
well,  but  in  alveolar  abscess  there  may  be  still  another  element 
which  does  not  appear  in  necrosis  of  bone  elsewhere.  Sometimes 
fibers  of  the  peridental  membrane,  covering  the  root  end  or  some 
portion  upon  the  side  of  the  root,  may  be  destroyed  during  the 


342  SPECIAL    DENTAL    PATHOLOGY, 


Fl(is.  412  TO  41(j.  A  series  illustiatiiig  iicutc  and  chronic  alveolar  abscess 
occurring  in  the  lower  incisor  region. 

Fig.  412.  Acute  alveolar  abscess  from  lower  incisor  pointing  on  the  gum: 
a.  Abscess  cavity  in  the  bone,  b,  Sinus  opening,  c,  Lip.  d,  Tooth.  In  this  case  the 
pus  has  penetrated  the  periosteum  without  lifting  it  from  the  bone. 

Fig.  413.  Acute  alveolar  abscess  from  lower  incisor  with  pus  cavity  between 
the  bone  and  the  periosteum:  a,  Pus  cavity  in  the  bone,  b,  Pus  between  the  peri- 
osteum and  bone,    c,  Lip.    d,  Tooth. 

Fig.  414.  Chronic  alveolar  abscess  at  the  root  of  a  lower  incisor:  a,  Abscess 
cavity  in  the  bone,    b,  Sinus  discharging  on  the  gum.     c,  Lip.     d,  Tooth. 

Fig.  415.  Chronic  alveolar  abscess  at  the  root  of  a  lower  incisor  with  sinus  dis- 
charging on  the  face  under  the  chin:  a,  Abscess  cavity  in  the  bone,  b,  b,  b,  Sinus 
following  the  periosteum  down  to  the  lower  margin  of  the  body  of  the  bone  and 
discharging  on  the  skin,    c,  Lip.     d,  Tooth. 

Fig.  416.  Chronic  alveolar  abscess  at  the  root  of  a  lower  incisor  with  abscess 
cavity  passing  through  the  body  of  the  bone  and  discharging  on  the  skin  beneath  the 
chin:     a,  Very  large  abscess  cavity,     b,  Mouth  of  the  sinus. 


Fie,.    4  1lJ. 


Fig.  413. 


Fiu.  -lli. 


Fiu.  415 


Fk;.  417.     .liilN 


Fig.  4 is.     Aug.  fi. 


FlC.     ll'.t.      Sept.    l^!l. 


Fig.  421.     Dec. 


Fig.  4-2-2.     F.h.    1. 


Figs.  417  to  422.     A  serios  of  radidgiaiilis  of  a  case  of  acute  alveolar  abscess 
from  an  upper  cuspid.     A  distal  gold  filliiig  was  placed  in  this  tootli  on  December  23, 

1913,  the  pulp  being  vital  at  the  time.     The  tooth  remained  comfortable  until  July  27, 

1914,  when  the  ])atieut  presented  with  an  acute  abscess,  which  was  lanced  at  once,  and 
a  radiograph  taken;  Figure  417.  The  root  was  tilled  August  6,  when  the  second 
radiograph,  Figure  41 S,  was  taken.  The  other  radiographs  were  made  on  the  dates 
mentioned,  showing  the  gradual  building  in  of  the  bone.  There  is  some  question 
whether  or  not  this  case  will  fully  lieal,  as  it  is  proljable  that  the  pulp  died  soon  after 
the  filling  was  placed  and  a  lilind  abscess  may  have  developed  without  symptoms, 
destroying  the  tissues  about  tlic  ;i]iix  previous  to  the  occurrence  of  the  acute  abscess. 
Case  from  practice  of  Dr.  Arthur  I).   Black. 


ACUTE    ALVEOLAR    ABSCESS.  343 

acute  inflammation  and  the  life  of  that  portion  of  the  cementum 
is  lost  and  the  part  denuded  becomes  pus  soaked.  This  pus- 
soaked  cementum  then  serves  to  maintain  a  chronic  abscess,  just 
the  same  as  would  a  spicula  of  necrosed  bone,  with  the  difference 
that  the  pus-soaked  area  of  cementum  can  not  be  exfoliated,  as 
would  be  the  case  with  the  piece  of  dead  bone. 

These  two  items  of  diiference  between  alveolar  abscess  and 
other  abscesses  of  the  body  render  it  a  special  form  of  abscess, 
presenting  interferences  to  the  healing  process  which  require 
special  technical  treatment. 

Symptoms. 

The  general  rule  is  that  periapical  inflammations  of  the  peri- 
dental membrane  are  short  and  decisive,  presenting  characters 
of  rapidly  growing  intensity,  running  their  course  to  suppura- 
tion within  a  few  hours.  The  progress  from  the  condition 
exhibiting  no  symptoms  whatever  to  a  definite  acute  alveolar 
abscess  may  be  so  rapid  that  the  intermediate  state  of  apical 
pericementitis  will  not  be  recognized ;  or  the  inflammation  may 
be  of  such  a  low  grade  from  the  first  that  a  chronic  alveolar 
abscess  will  be  formed  and  exist  for  a  considerable  time  —  possi- 
bly for  years  —  without  symptoms  which  will  have  in  any  way 
attracted  the  attention  of  the  patient. 

Constitutional  symptoms.  The  constitutional  symptoms 
usually  consist  of  a  sudden  rise  of  temperature,  often  ranging 
from  102°  to  105°,  with  a  correspondingly  rapid  pulse.  In  a 
few  cases  I  have  seen  a  temperature  of  106°.  There  may  be  a 
chill  preceding  the  fever.  The  patient  may  complain  of  head- 
ache, malaise  and  other  symptoms  commonly  accompanying  an 
acute  infection.     A  blood  count  will  show  a  leucocytosis. 

Local  symptoms.  The  local  symptoms  of  acute  alveolar 
abscess  are :  (1)  More  or  less  soreness  of  the  tooth ;  (2)  a  slight 
protrusion  of  the  tooth  from  the  alveolus;  (3)  tenderness  of  the 
tooth  to  use  in  mastication,  or  to  the  touch  of  the  teeth  of  the 
opposite  jaw,  or  to  percussion;  (4)  sometimes  looseness  of  the 
tooth;  (5)  pain,  which  may  be  very  persistent  and  of  a  dull 
character,  or  which  may  increase  very  rapidly  in  severity; 
(6)  there  may  be  a  general  hyperemia  affecting  more  or  less  of 
the  gum  tissue,  especially  on  the  labial  or  buccal  side,  where  the 
tissues  are  thinnest;  (7)  swelling  of  the  neighboring  tissues; 
(8)  an  accumulation  of  pus  indicated  ])y  fluctuation. 

Tenderness  of  tooth.  The  most  prominent  early  sjnnptom 
is  likely  to  be  the  soreness  of  the  tooth.     It  will  be  tender  to  the 


344  SPECIAL   DENTAL,   PATHOLOGY, 

touch,  it  may  be  slightly  protruded  by  the  inflammation  in  the 
periapical  space.  The  inflammation  may  cause  a  relaxation  of 
the  fibers  of  the  peridental  membrane  so  that  the  tooth  is  loose 
in  its  socket.  There  is  generally  no  redness  or  swelling  of  the 
gum  tissue  at  this  time. 

Pain  and  swelling.  ^ATien  pus  formation  occurs  rapidly, 
there  is  an  increasing  soreness  which  leads  to  a  throbbing  char- 
acter of  the  pain.  The  peridental  membrane  of  the  region, 
while  a  little  thicker  than  elsewhere,  is  only  a  small  amount  of 
tissue,  which  lies  between  the  apex  of  the  root  and  the  walls  of 
the  alveolus.  In  this  confined  space  the  sharp  inflammatory 
movement  grows  worse,  and  the  pain  becomes  intense,  being 
increased  by  every  pulse  beat.  If  the  case  is  running  a  rapid 
course,  fever  will  develop  at  this  stage  and  increase  in  severity 
as  the  inflammatoiy  movement  and  pus  formation  increases. 
The  pain  may  become  almost  intolerable. 

When  the  pus  has  forced  an  exit  through  the  periosteum 
to  the  soft  tissues  covering  it,  the  pressure  within  the  bone  is 
relieved,  and  almost  immediately  the  intensity  of  the  pain  dimin- 
ishes and  more  or  less  swelling  occurs,  with  marked  extensions 
of  the  hyperemic  movement  all  about  it,  reddening  the  surface 
generally;  so  that  patients  often  report  that  the  pain  ceased 
when  the  face  swelled,  and  yet  that  is  not  quite  true.  It  is  a 
fact,  however,  that  the  pain  is  usually  greatly  moderated  just 
at  this  juncture.  In  a  few  cases  the  swelling  at  this  time  will 
become  enormous.  If  the  case  be  in  the  upper  jaw,  it  is  not  very 
unusual  for  the  eye  of  that  side  to  be  closed,  and  the  patient 
unable  to  open  it  because  of  the  swelling  of  the  lids  and  of  the 
soft  areolar  tissue  about  it.  In  some  of  the  severer  cases,  the 
swelling  may  involve  almost  all  the  tissues  of  the  side  of  the 
face.  If  the  abscess  occurs  in  the  lower  jaw,  the  upper  face  will 
not  swell  so  much,  but  the  swelling  will  involve  the  floor  of  the 
mouth  and  the  tissues  of  the  cheek  and  of  the  angle  of  the  neck, 
rather  more  than  the  tissues  of  the  face,  and  present  a  greater 
tendency  for  the  pus  to  be  discharged  upon  the  face  or  neck.  It 
is  usually  during  this  swelling  of  the  soft  tissues  that  the  tem- 
perature is  highest.  Cases,  however,  vary  from  this  ugly  pic- 
ture to  the  milder  forms  which  present  little  or  no  swelling,  and 
little  or  no  pain.  Between  these  two,  any  variety  of  rapidity 
of  progress  of  inflammatory  movement,  and  of  fever  or  lack  of 
fever,  may  occur,  possibly  continuing  for  several  weeks. 

Ball-like  tumor.  When  the  pus  escapes  from  the  bone  and 
passes  through  the  periosteum  into  the  connective  tissues,  an 


ACUTE    ALVEOLAR    ABSCESS.  345 

examination  with  the  finger  will  discover  a  ball-like  tumor,  within 
which  an  area  of  fluctuation  may  be  made  out.  This  tumor  is 
inclined,  in  the  great  majority  of  the  cases,  to  point  on  the  gum 
somewhere  in  the  neighborhood  of  the  nearest  approach  to  the 
root  of  the  tooth  involved,  and  will,  if  left  to  itself,  make  an 
opening  upon  the  surface  of  the  gum  tissue  and  discharge  its  pus 
into  the  mouth.     (See  Figures  403  and  412.) 

Flat  twnor.  In  cases  in  which  the  periosteum  is  not  pene- 
trated, but  is  stripped  from  the  bone  and  the  pus  accumulates 
between  it  and  the  bone,  the  tumor  is  broad  and  flat.  It  is  more 
difficult  to  detect  the  presence  of  pus  by  palpation,  on  account  of 
the  tenseness  of  the  periosteum.  Failure  of  proper  diagnosis  at 
this  stage  inclines  to  the  postponement  of  surgical  interference, 
and  necrosis  of  the  involved  bone  frequently  results.  (See 
Figures  405,  406,  409  and  413.) 

Painful  symptoms  disappear  ivith  discharge  of  pus.  As 
soon  as  the  pus  has  been  discharged  from  either  of  these  fonns 
of  abscesses,  the  painful  symptoms  disappear  almost  at  once. 
A  lingering  soreness  continues  for  some  days,  the  swelling  dis- 
appears and  the  patient  becomes  comparatively  free  from  sub- 
jective symptoms,  but  the  abscess  does  not  get  well.  The  pus 
becomes  less  and  less  until  only  a  small  amount  is  discharged. 
The  tooth  can  be  used  in  mastication  the  same  as  before  and 
resumes  its  normal  work,  but  there  is  still  a  continuous  discharge 
of  pus  from  the  opening  on  the  gum,  or  from  the  tissues  wherever 
an  opening  has  become  established,  whether  it  be  on  the  face  or 
elsewhere.  This  is  chronic  alveolar  abscess,  which  will  be 
described  later. 

The  symptoms  of  amelioration  which  mark  the  change  from 
the  acute  to  the  chronic  variety  of  alveolar  abscess  do  not  admit 
of  specific  designation  as  to  when  the  acute  variety  is  ended,  and 
the  chronic  form  has  become  established.  We  generally  consider 
the  chronic  form  established,  however,  when  the  tooth  is  well 
enough  to  return  to  its  ordinary  work  of  mastication. 

Differential  diagnosis  between  acute  alveolar  abscess  and 
certain  other  conditions. 

While  there  is  usually  little  difficulty  in  making  a  positive 
diagnosis  in  cases  of  acute  alveolar  abscess,  there  are  several 
conditions  which  may  present  symptoms  which  will  require  a 
differential  diagnosis.  The  most  important  of  these  are  certain 
tumors,  more  particularly  sarcoma  and  gnmmn,  also  aneurism. 
cysts,  and  glandular  enlargements.     It  is  not  witliin  the  scope  of 


346  SPECIAL   DENTAL   PATHOLOGY. 

this  book  to  go  into  detail  in  the  differential  diagnosis  of  these 
conditions,  but  to  call  attention  to  them  and  mention  the  most 
important  differential  symptoms.  In  all  cases  in  which  there 
is  any  question  as  to  the  diagnosis,  careful  inquiry  should  be 
made  into  the  history,  as  a  basis  for  a  proper  and  thorough 
examination. 

Saecoma.  Sarcoma  will  be  differentiated  by  the  fact  that 
the  swelling  is  of  slower  development  than  in  cases  of  abscess, 
usually  without  painful  symptoms,  and  the  enlargement  is  felt 
to  be  a  solid  mass  of  tissue  without  fluid  contents.  In  some  cases 
of  alveolar  abscess,  however,  particularly  if  the  pus  has  lifted  the 
periosteum  without  having  penetrated  it,  it  may  be  impossible 
to  detect  fluctuation.  A  radiograph  of  a  giant  cell  sarcoma  of  the 
lower  jaw  is  shown  in  Figure  423. 

Gumma.  Syphilitic  gumma  may  occur  about  the  mouth  in 
positions  in  which  alveolar  abscesses  occur,  more  frequently  in 
the  upper  jaw.  These  are  also  of  slower  development,  usually 
without  pain,  and  the  mass  is  recognized  as  a  solid  tissue  growth. 
In  such  cases  there  are  other  symptoms  of  syphilis,  which  will  be 
elicited  by  further  inquiry  into  the  history  and  a  "Wasserman- 
test.  While  the  Wassennan  reaction  is  generally  to  be  relied 
upon,  it  should  be  remembered  that  occasionally  a  case  known  to 
be  syphilitic  gives  a  negative  Wasserman. 

Aneurism.  An  aneurism  of  the  posterior  palatine  artery 
might  be  mistaken  for  an  alveolar  abscess  which  had  penetrated 
the  bone  of  the  palate.  This  should  be  differentiated  by  the 
absence  of  fever  and  pain,  by  the  fact  the  tumor  may  be  reduced 
by  pressure,  and  by  the  pulsations.  It  might  be  difficult  to  con- 
trol the  hemorrhage  from  an  aneurism  in  this  position  if  the 
tissues  should  be  incised.  However,  aneurism  of  the  posterior 
palatine  artery  is  rare. 

Cysts.  Cysts  within  the  maxillary  bones  occur  quite  fre- 
quently. These  may  present  as  fluctuating  tumors.  They  are 
of  gradual  growth,  without  inflammatory  symptoms,  and  usually 
without  pain.  A  radiograph  will  usually  show  a  smooth  regular 
outline  to  the  cavity,  indicating  the  pressure  destruction  of  the 
bone,  as  compared  with  a  more  irregular  destruction  in  abscess 
formation.  The  fluid  of  the  cyst  is  clear,  of  yellowish  color, 
odorless,  and  viscid;  it  may  be  drawn  out  into  strings  of  con- 
siderable length.  The  subject  of  cyst  formation  in  connection 
with  alveolar  abscess  is  treated  elsewhere.  Figures  424  and  425 
are  radiographs  of  cysts,  and  Figure  426  is  a  photograph  of  a 


ACUTE    ALVEOLAR    ABSCESS.  347 

skull  showing  a  cyst  cavity.  The  smooth  outline  of  these  cyst 
cavities  will  be  noted. 

Examine  fluid  contents.  In  all  tumors  containing  fluid  in 
which  there  is  uncertainty  as  to  the  diagnosis,  some  of  the  con- 
tents should  be  withdrawn  with  an  aspirating  needle,  or  the 
tumor  may  be  punctured  with  a  grooved  needle,  and  by  turning 
this  back  and  forth,  some  of  the  contents  will  escape  along  the 
groove. 

Glands.  The  submaxillary  or  sublingual  glands  may  be 
enlarged  on  account  of  obstructions  of  their  ducts,  or  as  a  result 
of  infections  involving  the  glands.  The  cervical  lymphatic 
glands  may  be  enlarged  as  a  result  of  infections  anywhere  in  the 
region  which  they  drain.  When  the  cervical  lymphatics  are 
found  enlarged,  careful  search  should  be  instituted  and  contin- 
ued until  the  cause  is  learned. 

Eruption  of  third  molars.  Inflammations  often  occur  in 
connection  with  the  eruption  of  the  third  molars,  and  especially 
as  a  result  of  abnormal  positions  of  these  teeth.  It  is  sometimes 
difficult  to  differentiate  these  from  alveolar  abscess,  because  it 
may  be  impossible  to  open  the  mouth  sufficiently  for  a  thorough 
examination.  In  many  cases  a  radiograph  will  be  of  material 
assistance.  If  the  mouth  can  not  be  opened  to  permit  the  use  of 
a  small  film,  this  region  of  the  angle  of  the  jaw  can  be  well  shown 
on  a  plate  by  having  the  direction  of  the  rays  such  as  to  miss  the 
jaw  of  the  opposite  side. 

Lateral  alveolar  abscess,  septal  abscess  and  gingival  abscess, 
together  with  the  points  of  differentiation  from  true  alveolar 
abscess,  have  already  been  mentioned. 

In  all  cases,  a  critical  examination  of  the  teeth  of  the  region 
is  important.  If  they  respond  to  tests  for  pulp  vitality,  alveolar 
abscess  is  excluded.  It  is  of  course  recognized  that  teeth  which 
do  not  respond  may  have  had  the  pulps  removed  and  may  be 
excluded  by  radiographs ;  also  that  teeth  which  have  dead  pulps 
may  not  have  caused  an  infection  of  the  periapical  tissue.  Sev- 
eral of  the  conditions  mentioned  are  not  frequently  observed  by 
dentists  and,  whenever  there  is  doubt,  a  physician  or  surgeon 
should  be  called  in  consultation.  No  case  should  bo  dismissed 
until  every  means  to  a  proper  diagnosis  has  been  employed. 

As  illustrating  the  need  of  careful  differential  diagnosis,  I 
cite  the  following  cases  reported  by  Dr.  Tliomas  L.  Gilmer  in 


348  SPECIAL   DENTAL   PATHOLOGY. 

a  paper*  on  alveolar  abscess  read  before  the  Chicago  Dental 
Society. 

''First  case:  Patient,  woman,  forty  years  of  age.  There 
was  extensive  swelling  under  the  mandible  near  the  angle,  which 
extended  forward  and  up  the  cheek.  There  was  a  slight  trismus, 
which  prevented  complete  opening  of  the  jaws ;  temperature 
102° ;  there  was  much  pain  and  general  discomfort. 

'*0n  examining  the  teeth  I  found  all  of  the  pulps  alive  on 
this  side  of  the  mouth.  The  third  molar  had  been  removed 
jfifteen  years  before,  therefore  infection  from  an  impacted  tooth 
was  excluded.  There  was  no  indication  of  a  lesion  in  any  part 
of  the  mouth  or  on  the  face.  The  tonsils  were  normal  and  no 
pre\dous  history  of  tonsilitis,  or  cervical  or  submaxillary  lymph- 
adenitis could  be  elicited.  Owing  to  the  swelling,  it  was  difficult 
to  palpate  the  submaxillary  salivary  gland.  No  stone  was  found 
in  Wharton's  duct,  but  the  tube  was  enlarged  and  hard.  Pres- 
sure upon  the  submaxillary  gland  and  stripping  of  Wharton's 
duct  caused  pus  to  flow  from  the  duct.  Here  was  the  secret  of 
the  clinical  manifestations.  It  was  an  infection  of  the  submax- 
illary gland,  which  had  caused  the  condition,  and  gave  some  of 
the  symptoms  of  acute  alveolar  abscess. 

"Second  case:  Patient,  boy,  14  years  of  age.  He  was 
assigned  to  mj"  service  at  St.  Luke's  Hospital,  after  diagnosis  of 
alveolar  abscess  had  been  made.  On  examination  of  the  patient, 
I  found  a  large,  red,  shiny  swelling  extending  from  the  neck  up 
to  near  the  malar  bone,  from  back  of  the  angle  of  the  mandible 
forward  to  the  region  of  the  first  lower  bicuspid.  There  was* 
slight  pain ;  temperature  100° ;  blood  showed  14,000  leucocyte 
count. 

"Owing  to  the  great  swelling  I  was  unable  to  palpate  any  of 
the  glands  under  the  jaw,  or  in  the  cervical  region.  Wharton's 
duct  appeared  normal.  The  history  elicited  the  information  that 
the  swelling  came  on  rather  slowly,  ten  days  since  it  had  first 
been  noticed.  There  was  occasional  trismus,  but  the  jaw  could 
be  sufficiently  opened  to  make  a  careful  examination  of  the  mouth 
and  teeth.  All  of  the  permanent  teeth  were  in  place  except  the 
third  molars.  Those  erupted  were  sound  and  none  of  them  were 
sore  to  the  touch.  The  teeth  were  cleaner  than  is  usually  found 
in  the  mouth  of  such  a  child.  The  pulps  in  the  teeth  all 
responded  to  the  faradic  current  test.     The  teeth  were  excluded. 

*  Etiology,  Diagnosis   and   Treatment    of   Acute   and   Chronic   Alveolar   Abscess, 
Dental  Review,  Vol.  28,  1914,  p.  427. 


Fig.  423. 


Fig.  424. 


Fig.  425. 


Fig.  423.     Radiograph  of  a   case  of  ti  fjiaiit  cell    saiconia    in    (lie    rcijidM   of   IIk 
lower  cuspid  and  first  bicuspid. 

Fig.  424.     Radiograph  of  a  case  of  a  cyst  of  tiio  lower  jaw,  hoy  Iwclvc  years  old 
The  smooth  oiitliiie  of  the  area  of  bone  destroyed  is  sliown. 

Fig.  425.  Radiograph  of  a  case  of  a  cyst  in  Ihe  npi 
apices  of  the  bicuspid  roots  have  been  forced  apart  \>\  iIh 
cyst. 

32 


r   bicuspid   region.     The 
]>ressure  exerted   by  the 


Fig.  426. 


Fig.  426.     A  lower  maxilla  showing  a  smoothly  rounded  cavity,  evidently  made 
by  a  cyst.     Specimen  from  Northwestern  University  Dental  IMiiseum. 


ACUTE  ALVEOLAE  ABSCESS.  349 

The  tonsils  were  enlarged,  red  and  somewhat  ragged.  The  child 
said  that  he  had  often  had  sore  throat ;  that  twice  before  he  had 
a  slight  swelling  under  the  mandible,  and  that  preceding  this 
attack,  and  also  preceding  the  previous  attack,  he  had  felt 
''kernels"  (enlarged  IjTnph  nodes)  under  the  jaw. 

''Diagnosis:  Suppurative  lymph-adenitis,  secondary  to 
tonsilar  infection.  On  palpation  I  thought  I  was  able  to  make 
out  very  deeply  in  the  tissues  a  slight  fluctuation.  I  incised  the 
sMn  and  made  blunt  dissection,  liberating  a  considerable  quan- 
tity of  creamy  pus. '  * 


*32 


350  SPECIAL    DENTAL   PATHOLOGY. 


TREATMENT  OF  ACUTE  ALVEOLAR  ABSCESS. 

ILLUSTK.VTIONS:    FIGURES  427-429. 

It  must  be  held  distinctly  in  mind  that  the  forerunning  con- 
dition which  produces  alveolar  abscess  is  the  death  of  the  pulp 
of  the  tooth.  The  infection  which  occurs  in  the  destruction  of 
the  pulp  by  suppuration  and  saprophytic  decomposition  passes 
through  the  apical  foramen,  infecting  the  tissues  in  the  apical 
space.  In  some  cases  this  inflammation  may  be  slight,  but  in 
most  cases  it  passes  quickly  into  pus  formation. 

Usually  the  organisms  enter  the  pulp  tissue  through  a  cavity 
of  decay  in  the  tooth  which  has  exposed  the  pulp,  although  they 
doubtless  reach  the  pulp  in  a  limited  number  of  cases  through 
the  blood  stream.  There  is  much  evidence  now  that  micro- 
organisms may  remain  in  the  tissues  for  months  and  even  years 
and  then  be  brought  b}'^  the  blood  stream  to  a  point  of  injury 
and  there  set  up  an  infection.  Thus  there  may  be  pus  forma- 
tion in  the  apical  space  after  the  death  of  the  pulp  in  a  tooth  in 
which  there  is  no  cavity. 

During  apical  pericementitis. 

The  first  object  in  treatment  would  seem  to  be  the  shutting 
off'  of  the  ingress  of  micro-organisms  through  the  apical  fora- 
men, but  this  would  be  impracticable  in  the  larger  proportion  of 
cases  until  after  the  acute  symptoms  have  subsided.  However, 
should  the  case  present  during  the  stage  of  apical  pericementitis, 
or  when  there  is  hope  of  aborting  the  formation  of  an  abscess, 
the  root  canal  should  be  cleaned  at  once. 

In  such  cases,  some  form  of  counter  irritation  should  be 
employed.  I  have  usually  preferred  to  saturate  a  bit  of  gauze 
or  cotton,  small  enough  to  be  covered  by  the  finger,  in  chloro- 
form and,  after  absorbing  away  the  excess,  place  it  upon  a  piece 
of  rubber  dam,  a  little  larger  than  can  be  covered  by  the  finger, 
and  apply  this  to  the  gum  over  the  root  of  the  tooth  affected. 
It  should  then  be  held  with  the  finger  until  a  sharp  burning  of 
the  tissue  occurs.  Then  it  may  be  removed  for  a  time  and  reap- 
])lied.  This  may  be  done  several  times  at  one  sitting,  possibly 
producing  a  blister.  It  has  seemed  to  me  that  this  treatment 
gives  better  results  if  it  is  stopped  short  of  forming  a  blister. 


ACUTE    ALVEOLAE    ABSCESS.  351 

Oftentimes  this  will  produce  at  least  temporary  relief.  Various 
other  forms  of  counter  irritation  have  been  used,  sucli  as  canthar- 
ides  plasters,  and  other  like  irritants.  A  saline  cathartic  should 
be  regularly  ordered,  also  a  hot  foot  bath  before  the  patient 
retires.     All  of  these  are  palliative  rather  than  curative. 

The  tooth  may  be  given  rest  by  building  up  the  occlusal 
surfaces  of  other  teeth  with  cement.  I  prefer  the  oxyphosphate 
of  copper  cement  for  this  purpose,  because  it  adheres  better, 
applying  a  thin  layer  on  the  occlusal  surfaces  of  the  bicuspids 
and  molars  of  both  sides  of  one  arch,  except  of  course  in  the 
position  of  the  tender  tooth. 

Secure  good  drainage. 

Most  cases  of  acute  alveolar  abscess  present  with  a  sore 
tooth,  the  soreness  having  developed  very  recently,  and  it  is 
found  that  the  pulp  of  this  tooth  is  dead  —  the  pulp  chamber 
may  be  open  or  not  —  and  the  case  is  becoming  worse  from  hour 
to  hour.  The  first  treatment  should  be  to  obtain  drainage  for 
the  pus  and  relieve  the  pain.  The  conditions  in  the  particular 
case  will  indicate  the  plan  of  treatment  to  be  followed.  There 
are  two  routes  by  which  the  abscess  cavity  may  be  reached: 
(1)  through  the  root  canal,  and  (2)  through  the  gum  and  alveolar 
process,  or  in  some  cases  externally  on  the  face  or  neck. 

Through  pulp  chamber.  If  the  tooth  is  not  too  sore,  and  if 
the  case  has  not  progressed  to  the  stage  when  a  tumor  contain- 
ing pus  may  be  palpated,  an  attempt  should  be  made  to  open  the 
pulp  chamber  sufficiently  and  clean  it  and  the  root  canals.  Some- 
times fairly  thorough  mechanical  cleaning  of  the  root  canals, 
especially  if  the  canals  are  large  enough  to  permit  a  broach  to 
be  passed  through  the  apical  foramen,  will  give  relief,  by  thus 
giving  drainage  through  the  canals.  When  this  is  done  the 
rubber  dam  should  be  in  place,  and,  after  the  canals  have  been 
cleansed,  a  dressing  should  be  securely  sealed,  as  has  been 
described  in  the  technic  of  pulp  treatment. 

Through  investing  tissues.  The  other  plan,  which  should 
be  more  generally  followed,  is  to  make  an  incision  through  the 
gum  for  the  discharge  of  the  pus,  leaving  the  treatment  of  the 
pulp  chamber  and  root  canals  until  immediately  after  the  acute 
symptoms  have  subsided.  In  those  cases  in  which  a  fluctuating 
tumor  may  be  palpated,  whether  the  pus  he  under  the  periosteum 
or  outside  of  it,  an  incision  is  positively  indicated  as  a  first  pro- 
cedure, regardless  of  the  condition  of  soreness  of  the  tooth. 

In  those  cases  which  present  previous  to  the  formation  of  a 


352  SPECIAL   DENTAL,   PATHOLOGY. 

palpable  tumor,  but  with  the  tooth  too  sore  to  justify  an  attempt 
at  treatment  through  the  pulp  chamber,  and  also  in  cases  in 
which  treatment  through  the  pulp  chamber  has  been  tried  with- 
out securing  reasonably  prompt  relief,  one  of  the  very  best 
expedients  is  to  make  a  considerable  cut  through  the  gum  tissue 
to  the  bone  as  near  the  apical  end  of  the  root  as  is  practicable. 
This  will  differ  with  different  teeth.  In  making  this  cut,  the 
edge  of  the  knife  should  be  pushed  to  one  side  and  then  to  the 
other,  in  order  to  tear  up  the  periosteum  from  the  bone  over  a 
space. 

Advantages  of  early  incision.  Several  advantages  will  often 
be  gained  by  such  an  incision.  The  hemorrhage  will  relieve  the 
congestion  and,  if  a  slight  amount  of  pus  should  have  penetrated 
the  bone  and  reached  the  periosteum,  relief  will  be  secured.  If 
the  pus  has  not  yet  reached  the  outer  plate  of  bone,  the  opening 
will  verj^  likely  be  found  by  it  within  a  few  hours,  and  the  dura- 
tion of  the  pain  will  thus  be  cut  short.  The  possibility  that  the 
periosteum  will  be  lifted  from  the  bone  will  be  avoided  and 
necrosis  will  often  be  prevented.  There  seems  therefore  to  be 
every  reason  for  an  early  incision  to  and  through  the  perios- 
teum. It  would  be  much  better  if  earlier  incision  were  made  in 
practically  all  cases.  Even  though  such  an  incision  should  be 
occasionally  made  when  not  absolutely  necessary,  no  harm  would 
be  done.  My  observ^ation  of  hundreds  of  cases  in  which  serious 
complications  have  occurred  as  the  result  of  failures  to  make 
incisions  early,  or  not  at  all,  leads  me  to  strongly  emphasize  the 
desirability  of  more  prompt  surgical  interference  in  these  cases. 

Incision  should  be  ample  for  good  drainage.  In  opening  an 
abscess,  an  incision  should  be  made  that  will  give  very  free  exit 
to  the  pus.  The  incision  should  usually  be  from  three-fourths 
of  an  inch  to  a  full  inch  in  length.  If  a  very  small  cut  is  made, 
good  drainage  is  not  secured,  and  a  second  incision  will  be  neces- 
sary. There  is  practically  no  difference  in  the  pain  caused  in 
making  a  slight  or  a  liberal  opening. 

Operators  differ  as  to  the  best  direction  for  the  incision. 
Some  make  it  high  on  the  process,  parallel  with  the  length  of  the 
jaw.  It  has  been  my  habit  to  enter  the  lance  high  up,  stretching 
the  mucous  membrane  away  for  that  purpose,  and  make  the 
incision  parallel  with  the  long  axis  of  the  tooth,  as  far  as  mid- 
way of  the  root  or  a  little  farther.  Then,  by  moving  the  end  of 
the  blade  to  one  side  and  then  to  the  other  in  this  cut,  the  perios- 
teum may  be  cut  or  torn  away  from  the  bone  for  a  little  distance. 


ACUTE  ALVEOLAR  ABSCESS.  353 

If  the  pus  flows  freely  about  the  knife,  this  lateral  motion  of  the 
instrument  may  be  omitted. 

If  a  broad,  fiat  tumor  under  periosteum.  In  case  we  find  a 
broad,  flat  fluctuating  tumor  which  is  formed  by  the  pus  tearing 
up  the  periosteum  and  remaining  between  the  periosteum  and 
bone,  a  very  broad  opening  should  be  made.  It  is  from  this  class 
of  cases  that  necrosis  of  bone  as  a  sequela  of  alveolar  abscess 
practically  always  occurs  and  the  drainage  afforded  should  be 
such  that  the  pressure  will  be  unquestionably  relieved  and  the 
periosteum  will  drop  back  to  its  proper  place.  (See  Figures 
405,  409  and  413.) 

If  pus  has  not  reached  the  periosteum.  In  those  cases  in 
which  the  pus  has  not  reached  the  periosteum,  following  the 
incision  through  the  soft  tissues,  an  opening  may  be  made 
through  the  bone  to  the  region  of  the  apex  of  the  root.  This 
may  be  done  with  a  sharp  bibeveled  drill  in  the  engine.  This 
procedure  may  be  employed  in  only  a  limited  number  of  cases 
when  the  access  is  good.  The  severe  pain  will  be  relieved  in  a 
very  short  time.  The  operation  itself,  however,  is  often  very 
painful.  The  greatest  care  should  be  taken  not  to  cut  away  the 
peridental  membrane  from  any  part  of  the  root,  as  this  might 
produce  conditions  which  would  render  the  abscess  incurable. 

There  should  be  no  hesitancy  in  enlarging  openings  in  the 
bone,  if  sufficient  care  is  taken  to  avoid  injury  to  the  peridental 
membrane.  My  experience  has  been  that  there  is  no  tissue 
which  heals  much  more  kindly  than  does  bone,  and  cutting  the 
opening  larger  seems  to  make  but  little  difference  in  the  healing 
process. 

Anesthesia  for  incision.  The  incision  and  the  cutting  of  the 
bone  are  both  very  painful,  although  of  but  a  moment's  dura- 
tion. The  administration  of  nitrous  oxid  is  the  best  means  of 
securing  anesthesia.  The  u^e  of  novocain  locally  in  these  cases 
is  generally  not  satisfactory. 

Opening  made  with  phenol.  I  have  followed  another  plan 
in  an  occasional  case  which  was  slow  in  developing  and  in  which 
there  was  little  swelling  with  considerable  pain.  An  instrument 
fashioned  like  a  plugger,  but  with  longer  and  sharper  serrations, 
is  dipped  into  phenol  and,  after  being  withdrawn,  is  held  until 
there  is  a  single  small  drop  of  phenol  on  the  end  of  the  instru- 
ment. The  area  is  protected  by  cotton  rolls,  and  the  phenol  on 
the  end  of  the  instnmient  is  brought  to  the  spot  nearest  the 
apex  of  the  root,  and  applied.  At  once  it  whitens  a  small  area 
about  it.     When  this  has  occurred,  the  tissue  that  is  whitened  is 


354  SPECIAL    DENTAL   PATHOLOGY. 

removed  by  a  scraping  motion  of  the  plugger  point.  Then 
another  drop  of  phenol  is  apjilied  in  the  same  way,  and  the 
scratching  of  the  tissue  with  the  instrument  is  repeated.  The 
drawing  of  blood  by  the  scratching  of  the  instrument  should  be  a 
signal  to  clean  out  what  has  been  done,  and  apply  more  phenol 
liefore  proceeding.  An  opening  is  thus  gradually  made  through 
the  soft  tissues  to  the  bone.  The  walls  of  this  passage  are  so 
benumbed  by  the  phenol  that  they  may  be  stretched  wider  open, 
and  some  little  cutting  may  be  done  without  pain,  to  enlarge  the 
opening.  Then  with  a  blunt  instrument  the  periosteum  may  be 
raised  about  the  opening,  and  the  bone  may  be  penetrated  as 
detailed  above.  A  very  nervous  patient,  who  dreads  an  incision, 
may  appreciate  this  method,  although  it  requires  quite  a  little 
time. 

Ieeigation.  Following  the  incision,  it  has  been  my  habit  to 
veiy  thoroughly  irrigate  the  wound  with  salt  solution,  using  for 
this  purpose  either  the  large  rubber  bulb  syringe  or  a  fountain 
syringe.  This  has  always  been  done  with  a  syringe  point  having 
a  sufficiently  large  opening  to  permit  of  a  free  flow  of  the  solution 
without  much  pressure,  in  order  to  secure  the  most  thorough 
cleansing  and  at  the  same  time  avoid  the  danger  of  forcing  the 
infection  deeper  into  the  tissues.  It  is  also  necessary  that  the 
wound  be  well  opened,  to  give  opportunity  for  the  free  return 
flow  of  the  fluid,  otherwise  an  extension  of  the  infection  might 
result. 

During  recent  years  the  tendency  among  surgeons  has  been 
to  make  very  free  incisions,  and  omit  the  irrigation,  relying  upon 
packs  moistened  frequently  with  boric  acid  or  salt  solution  to 
keep  the  wound  patulous.  As  a  general  proposition  this  plan 
seems  to  be  giving  better  results,  although  it  applies  more  espe- 
cially to  hospital  rather  than  ambulatory  cases.  There  is  also 
a  greater  tendency  for  incisions  within  the  mouth  to  close,  as 
compared  with  those  made  through  the  skin. 

Packing.  In  no  case  should  the  precaution  to  keep  a  free 
opening  through  the  soft  tissue  be  neglected,  for  in  a  great  many 
cases  such  openings  heal  veiy  promptly.  I  have  seen  broad  cuts, 
through  which  pus  escaped  freely,  united  within  six  hours  so  that 
it  was  necessary  to  again  incise  the  tissues.  It  should  be  remem- 
bered that  the  gum  tissue  heals  very  quickly.  This  is  one  of  its 
characteristics. 

The  opening  in  the  soft  tissues  may  be  maintained  by  pack- 
ing in  a  small  strip  of  gauze.  This  should  not  be  packed  tightly 
enough  to  interfere  with  the  drainage.     The  gauze  may  be  first 


ACUTE  ALVEOLAR  ABSCESS.  355 

saturated  in  95  per  cent  phenol,  and  then  pressed  between  the 
folds  of  a  sterile  towel  until  the  gauze  or  cotton  is  practically  dry. 
This  should  be  carried  to  the  depth  of  the  cut  and  should  remain 
twenty- four  or  forty-eight  hours.  This  slight  amount  of  phenol 
on  the  gauze  serves  to  keep  the  opening  from  closing  as  rapidly 
as  it  otherwise  would.  It  is  not  used  with  the  intention  that  the 
phenol  will,  by  its  antiseptic  property,  promote  the  healing  of 
the  abscess,  but  to  retard  the  normal  activity  of  the  freshly  cut 
surfaces  toward  reuniting.  The  gauze  should  not  be  carried 
into  the  bone  cavity. 

Open  pulp  chamber  after  acute  symptoms  have  subsided. 

During  the  time  of  severe  soreness  of  the  tooth,  no  effort 
should  be  made  to  open  the  puljD  chamber.  The  tooth  is  tender ; 
every  touch  upon  it  hurts,  and  there  is  no  advantage  from  such 
interference.  The  incision  through  the  gum  will  relieve  the 
patient  of  pain  earlier  than  any  other  treatment,  and  the  opening 
of  the  tooth  and  cleaning  of  the  root  canals  should  be  deferred 
until  the  acute  symptoms  have  subsided.  Then  these  operations 
can  be  performed  without  pain.  Figures  417  to  422  are  repro- 
ductions of  radiographs  of  a  case  which  presented  on  July  27, 
1914,  with  an  acute  abscess  of  the  upper  cuspid.  (See  Figure 
417.)  After  the  acute  symptoms  had  subsided,  the  dead  pulp 
was  removed.  The  root  was  filled  and  the  second  radiograph 
(Figure  418)  was  taken  on  August  6.  Others  were  taken  at 
intervals  of  five  or  six  weeks,  and  show  the  gradual  building  in 
of  the  bone.     (See  Figures  419  to  422.) 

Treatment  of  the  More  Severe  Cases. 

From  the  above  description  of  the  treatment  of  alveolar 
abscess  it  would  seem  to  be  very  simple  and  effective,  and  this  is 
really  true  of  the  larger  percentage  of  cases.  But  there  are 
cases  presenting  which  are  much  more  difficult  of  management ; 
cases  which  seem  slow  in  the  formation  of  pus,  so  that  there  are 
a  number  of  days  of  excessive  pain  accompanied  with  swelling 
and  increasing  fever.  In  many  of  these  a  Hum))er  of  teeth  in  the 
neighborhood  will  be  tender  to  pressure  and  it  is  sometimes 
difficult  to  locate  the  tooth  which  is  the  cause  of  the  abscess. 
Cases  occur  in  which  the  swelling  of  the  tissues  may  be  extensive 
and  may  be  distressing  and  even  dangerous  by  its  interference 
with  other  functions;  as  for  example,  those  swellings  of  the 
floor  of  the  mouth  or  neck  which  interfere  with  deglutition  and 
respiration ;   and  those  about  tlie  angle  of  tlie  lower  jaw  whicli, 


356  SPECIAL   DENTAL   PATHOLOGY. 

together  with  the  spasm  of  the  muscles  attached  to  the  ramus, 
make  it  impossible  for  the  patient  to  open  the  mouth.  There 
seems  to  be  no  treatment  which  will  cut  short  the  course  of  some 
of  these  cases. 

Relief  of  pain  and  general  symptoms. 

Hot  fomentations.  In  these  a  further  effort  to  relieve  the 
pain  and  general  symptoms  should  be  made.  The  portion  of  the 
face  involved  may  be  wrapped  in  a  pack  wrung  out  of  hot  water. 
A  piece  of  flannel  or  coarse  cloth  may  be  dipped  into  the  hot 
water  and  laid  on  the  face.  A  heavy  towel  or  rubber  cloth  laid 
over  this  will  prevent  the  very  rapid  cooling  of  the  pack.  This 
should  be  kept  as  hot  as  the  patient  can  bear  for  fifteen  minutes 
or  more,  and  then  omitted  for  a  time,  and  repeated  as  often  as 
seems  desirable.  I  should  condemn  the  use  of  poultices  of  any 
kind  applied  on  the  face.  These  will  soften  the  tissues  and  favor 
the  exit  of  pus  on  the  face,  which  is  especially  to  be  avoided. 
A  rule  should  be  never  to  allow  pus  to  make  its  own  opening  on 
the  skin.  Whenever  such  an  opening  is  imminent,  a  cut  should 
be  made  to  discharge  the  pus.  This  is  for  the  reason  that  any 
opening  made  in  the  skin  by  suppuration  will  heal  with  an  ugly 
scar,  while  a  cut  made  with  the  knife  will  heal  almost  without  a 
scar. 

Saline  cathartic.  Hot  foot-bath.  A  large  dose  of  a  saline 
cathartic  should  be  a  part  of  the  regular  treatment  of  such  cases, 
and  tliis  should  be  repeated  whenever  necessary  to  keep  the 
bowels  very  free  until  after  good  drainage  of  the  abscess  has 
been  established.  Together  with  this,  the  patient  should  have  a 
hot  foot-bath,  which  should  be  continued  for  fully  fifteen  min- 
utes, previous  to  retiring  each  night. 

Anodynes.  Aspirin  may  be  given  to  relieve  the  pain,  when 
it  is  not  very  severe.  In  some  of  the  cases  in  which  the  pain  is 
the  principal  factor,  not  including  the  development  of  high  fever 
or  other  systemic  conditions  of'  importance,  I  have  used  some 
form  of  opiate  to  tide  the  patient  over  this  very  distressing  stage 
of  the  affection.  In  this  I  have  been  especially  impressed  with 
the  usefulness  of  svapnia,  usually  in  one  grain  doses  by  the 
mouth,  because  its  ameliorating  effect  will  extend  over  a  longer 
period  than  that  of  the  other  opiates.  It  is  not,  however,  so 
directly  effective  in  relieving  pain  as  some  of  the  other  forms, 
but  it  will  keep  the  patient  in  a  drowsy  state  for  twenty-four 
hours,  if  the  doses  are  properly  adjusted  to  the  individual.  This 
has  seemed  to  me  to  give  relief,  without  otherwise  influencing  the 


Fig,  427. 


Fio.  427.  Case  of  an  alveolar  abscess  from  the  upper  rijjlit  cuspid  which  was 
(liscliarfjiiig  i)(>ar  the  inner  cantlius  of  the  eye.  Tiiis  case  was  n-ferred  to  Dr.  Ciihner's 
clinic  at  Northwestern  University  J^ental  School.     Sec  description  of  wise  in  the  text. 


Fig.  428. 


Fig.  4129. 


Figs.  42S  and  4"29.  T'asc  of  iilvfolar  ahsress  from  a  lower  third  molar.  This 
patient  was  oporatcd  upon  by  Dr.  Carl  K.  Black.  See  description  in  the  text. 
Figure  428  was  taken  immediately  after  the  operation;  Fig.  429  after  the  wound 
hail  healed. 


ACUTE  ALVEOLAR  ABSCESS.  357 

progress  of  the  cases.  When  more  prompt  relief  is  desired. 
Ys  or  1/4  gr.  of  morphine  may  be  given  hypodermically. 

Drainage.  When  in  the  progress  of  these  cases  the  pus  has 
finally  been  discharged,  the  same  treatment  to  maintain  good 
drainage  should  be  used  as  in  the  other  cases.  This  effort  at 
cleanliness  should  be  vigorous  from  first  to  last.  In  all  cases 
there  should  be  a  close  watch  for  the  decomposition  of  pus,  and 
sufficiently  good  drainage  should  be  maintained  to  prevent  it. 
By  these  several  means,  the  more  severe  cases  can  generally  be 
brought  to  favorable  termination. 

Burrowing  of  pus.  Sometimes  it  will  be  found  that  the  pus 
in  rather  small  amounts  has  been  burrowing  in  this  direction  or 
that,  the  directions  being  variable,  so  that  no  one  detailed 
description  would  give  a  correct  idea  of  them.  These  are  to  be 
looked  for  continually  in  the  treatment  of  such  cases,  and  if  signs 
of  such  burrowing  should  be  found,  they  should  at  once  be  inves- 
tigated, and  the  incision  extended  as  may  be  necessary  for  drain- 
age. I  have  sometimes  followed  such  burrowings  down  upon  the 
neck,  or  into  other  regions  in  tracing  out  the  directions  taken 
by  the  pus.  A  knowledge  of  the  anatomy  and  of  the  fact  that 
pus  is  liable  to  become  entangled  in  the  fascia  of  muscles,  or  in 
the  muscular  tissue  itself,  and  follow  its  fibers,  is  always  some- 
thing of  a  guide  as  to  the  directions  the  pus  may  take,  but  a 
description  that  will  cover  the  cases  which  may  present  seems 
impracticable.  The  finding  of  these  will  depend  most  on  the 
acuteness  of  the  observer. 

I  recall  one  case  in  which  a  patient  presented  with  a  tremen- 
dous swelling  of  tissues  of  the  floor  of  the  mouth  and  of  the  neck 
from  the  left  sterno-cleido-mastoid  muscle  around  to  the  position 
of  the  mental  foramen  on  the  right  side.  The  tongue  was  also 
much  swollen.  There  was  discomfort  in  swallowing,  the  patient 
was  suffering  severely,  had  a  high  fever  and  could  not  open  the 
mouth  more  than  about  three-eighths  of  an  inch  at  the  incisors. 
No  area  of  fluctuation  could  be  found  by  palpation,  there  was 
nothing  in  the  history  of  the  case  to  indicate  the  tooth  which  was 
responsible  for  the  abscess,  and  it  was  out  of  the  question  to 
make  a  satisfactory  examination  of  the  teeth.  Although  it  was 
not  expected  that  pus  would  be  obtained,  the  skin  was  frozen 
with  a  spray  of  ethyl  chlorid  and  an  incision  was  made  at  about 
the  center  of  the  swelling.  The  cut  was  made  through  the  skin, 
about  one  and  one-half  inches  below  the  lower  border  of  the  bone 
at  the  position  of  the  left  mental  foramen,  the  direction  of  the 
blade  being  such  that  the  point  reached  tho  bone  near  its  lower 

33 


358  SPECIAL    DENTAL,   PATHOLOGY. 

border.  The  point  was  then  scraped  along  the  bone,  in  order  to 
certainly  cut  through  the  periosteum  for  possibly  an  inch.  The 
swelling  was  so  great  that  a  little  more  than  all  of  the  blade  of 
an  ordinary  scalpel  was  within  the  tissues.  There  was  consid- 
erable hemorrhage,  but  no  pus.  The  incision  was  packed  to 
prevent  it  from  closing.  Anodynes  were  given,  hot  fomentations 
applied,  'a  saline  cathartic  was  ordered,  also  a  hot  foot-bath 
before  retiring. 

The  next  day  there  was  practically  no  change  in  the  patient's 
condition,  except  that  the  difficulty  in  swallowing  was  increased, 
and  the  patient  was  alarmed  because  there  was  some  slight  inter- 
ference with  respiration.  No  pus  could  be  palpated.  The  knife 
was  inserted  into  the  opening  made  the  previous  day  and,  after 
reaching  the  bone,  was  carried  farther  along  it  in  ever3^  direc- 
tion, but  no  pus  was  found.  Anodynes,  hot  fomentations,  a 
saline  and  foot-bath  were  again  ordered.  On  the  third  day  condi- 
tions were  practically  the  same.  The  patient  was  very  weak  and 
very  much  alarmed.  Still  no  pus  could  be  palpated.  The  knife 
was  again  inserted  into  the  previous  opening,  but  on  reaching 
the  bone  was  directed  to  the  lower  border,  under  it  and  a  short 
distance  upward  on  the  lingual  side  of  the  bone.  This  incision 
was  successful  in  reaching  the  pus  and  possibly  half  a  teaspoon- 
ful  was  discharged.  The  wound  was  irrigated  and  packed  and 
the  patient's  recovery  was  rapid. 

In  this  case,  as  was  afterward  learned,  the  abscess  was 
caused  by  a  dead  pulp  in  the  lower  second  molar.  The  pus  had 
penetrated  the  bone  on  the  lingual  side,  below  the  attachment  of 
the  mylo-hyoid  muscle,  and  had  evidently  followed  along  the 
inner  surface  of  the  bone,  keeping  below  the  attachment  of  the 
muscle,  ripping  up  the  periosteum  without  penetrating  it.  It 
was  out  of  all  question  to  locate  the  pus  by  palpation,  as  the 
mouth  could  not  be  opened  sufficiently  to  admit  a  finger  between 
the  teeth,  and  there  was  so  much  swelling  that  nothing  could  be 
learned  by  an  external  examination;  it  was  only  possible  to 
locate  the  position  of  the  lower  border  of  the  bone  by  noting  it 
on  the  opposite  side.  This  was  an  unusual  case  in  the  route 
which  the  pus  followed,  and  it  was  only  after  very  extensive 
searching  that  it  was  found.  It  is  probable  that  had  this  patient 
been  taken  to  the  hospital  and  anesthetized,  the  mouth  could 
have  been  opened  and  the  pus  located  and  discharged  more 
promptly,  but  conditions  were  not  favorable  for  so  doing. 

A  very  interesting  case  presented  at  our  school  clinic  several 
years  ago,  and  was  under  Dr.  Gilmer's  care  in  the  department 


ACUTE  ALVEOLAR  ABSCESS.  359 

of  Oral  Surgery.  A  young  man  came  in  to  have  his  teeth  exam- 
ined, and  it  was  noticed  that  there  was  a  sore  on  the  right  side  of 
his  nose  almost  level  with  the  inner  canthus  of  the  eye.  A  little 
pus  was  discharging  from  this  sore.  The  patient  stated  that  the 
discharge  had  occurred  at  intervals  for  more  than  a  year  and 
all  efforts  to  cure  it  had  failed.  In  examining  the  mouth  a  sinus 
was  discovered  above  the  right  cuspid  root.  In  exploring  this, 
the  Examiner  passed  a  sharp  steel  probe  into  the  sinus  in  the 
mouth  and  it  came  in  contact  with  the  end  of  the  cuspid  root, 
about  which  there  was  a  cavity  within  the  bone.  Further  explo- 
ration with  a  silver  probe  revealed  a  sinus  which  terminated 
with  the  opening  on  the  side  of  the  nose.  The  case  was  then 
referred  to  the  Oral  Surgery  Clinic  and  Dr.  Gilmer  found  a 
necrosis  of  the  right  nasal  bone.  With  the  removal  of  the  bone 
and  the  extraction  of  the  tooth,  the  case  made  a  prompt  recover\\ 
Figure  427  shows  the  case,  with  a  probe  passed  through  the  sinus 
and  protruding  from  the  opening  on  the  side  of  the  nose. 

The  following  is  a  report  of  an  unusual  case  of  alveolar 
abscess,  taken  from  the  case  records  of  Dr.  Carl  E.  Black,  of 
Jacksonville,  Illinois : 

''G.  B.,  male;  age  48;  farmer;  married;  father  of  two 
children ;  circumstances  moderate,  home  surroundings  pleasant ; 
hard  worker;  no  bad  habits;  general  physical  condition  had 
always  been  excellent;  family  history  good.  Urine  showed  a 
trace  of  albumen  and  numerous  granular  casts. 

''The  last  of  January,  1910,  a  dentist  extracted  the  lower 
right  third  molar  on  account  of  pain  and  soreness  about  the 
tooth.  About  March  1,  patient  began  to  have  soreness  beneath 
the  chin  and  a  little  later  swelling  on  right  side  of  lower  part  of 
face.  After  several  days  he  consulted  a  physician  and  was 
referred  back  to  the  dentist,  who  told  the  patient  that  he  could 
find  no  cause  in  the  mouth  for  the  swelling  and  pain.  Patient 
then  consulted  another  dentist,  who  thought  some  part  of  the 
molar  tooth  was  still  in  the  jaw  and  was  the  cause  of  the 
trouble.  Patient  then  went  to  another  physician,  who  gave  him 
a  prescription  for  his  throat  and  applied  antiphlogistine  locally 
as  a  poultice  for  about  two  weeks.  The  condition  grew  worse, 
and  the  patient  consulted  another  physician  who  at  once  decided 
that  the  case  demanded  surgical  intervention  and  sent  him  to 
Passavant  Hospital  and  to  my  care. 

''When  I  first  examined  the  case,  March  31,  1910,  there  was 
a  tense,  painful,  fluctuating  swelling  involving  the  right  side  of 
the  face  and  extending  from  the  mastoid  process  to  beyond  the 


360  SPECIAL,   DENTAL   PATHOLOGY. 

median  line  of  the  chin  and  down  to  the  clavicle,  from  its  attach- 
ment to  the  sternum  to  its  middle.  There  was  a  constant  puru- 
lent discharge  from  the  mouth,  pouring  out  from  the  cavity 
where  the  molar  tooth  had  been  extracted. 

^ '  The  patient  was  given  a  general  anesthetic  (ether) .  After 
shaving  the  face  and  neck  an  incision  was  begun  at  the  angle 
of  the  jaw  and  extended  to  the  middle  of  the  clavicle.  This 
exposed  a  large  abscess  cavity  below  the  fascia,  or  rather  a  series 
of  abscess  cavities  connected  together  by  sinuses.  A  second 
incision  was  made  below  the  mastoid  and  a  third  in  the  median 
line  just  under  the  chin.  All  pockets  were  opened  and  broken- 
down  tissue  removed  and  all  incisions  connected  by  drainage 
tubes,  as  shown  in  Figure  428.  The  main  cavity  below  the  angle 
of  the  jaw  was  packed  wide  open  with  gauze.  One  cavity  was 
below  the  stemo-clido-mastoid  muscle.  No  attempt  was  made 
to  close  any  part  of  the  incision.  The  discharge  through  the 
mouth  at  once  ceased  and  the  wounds  healed  rapidly.  Patient 
left  the  hospital  on  April  23,  practically  well,  but  with  an  ugly 
scar  on  the  face  as  shown  in  Figure  429. 

''I  did  not  see  this  patient  again  until  October  5,  1910. 
Examination  at  this  time  showed  that  the  pain  in  the  right  arm 
at  the  time  of  the  acute  process  was  not  simply  a  referred  pain 
but  that  as  sequela  of  the  infection  he  had  had  a  brachial  neuri- 
tis resulting  in  permanently  diminished  sensation  in  the  palmer 
surfaces  of  the  fingers  of  the  right  hand.  The  muscles  between 
the  thumb  and  the  first  metacarpal  and  between  the  metacarpals 
of  the  little  and  ring  fingers  of  the  right  hand  were  much  atro- 
phied, and  the  power  of  the  hand  diminished  fully  one-half  for 
purposes  of  manual  labor." 

As  one  reads  the  report  of  this  case,  as  of  many  others  of  the 
more  severe  cases,  it  seems  evident  that  a  more  painstaking  and 
thorough  examination  leading  to  a  proper  early  diagnosis  would 
indicate  the  treatment  necessary  to  cut  them  short. 

Pkophylaxis  as  Applied  to  Alveolar  Abscess. 

Since  alveolar  abscess  is  a  sequela  of  the  death  of  the  pulp, 
all  that  has  been  said  relative  to  the  prevention  of  hyperemia 
and  inflammation  of  the  pulp,  and  of  the  treatment  of  hyperemia, 
is  the  best  prophylaxis  against  alveolar  abscess.  There  should 
be  added  the  necessity  of  careful  observation  and  watchfulness, 
directed  especially  to  those  conditions  which  precede  abscess 
development. 

If  a  tooth  should  have  a  hyperemia,  the  dentist  should  make 


ACUTE    ALVEOLAR   ABSCESS.  361 

a  record  of  the  condition  and  should  examine  the  tooth  at  subse- 
quent periods  to  ascertain  if  the  pulp  is  still  alive.  If  the 
hyperemia  is  severe  the  tooth  should  be  watched  until  it  has 
subsided,  giving  special  appointments  for  this  purpose,  if  neces- 
sary. If  a  tooth  has  occasionally  been  sore,  it  should  be  exam- 
ined to  see  whether  or  not  the  pulp  has  died,  and  if  it  has, 
treatment  should  be  undertaken  at  once.  Delay  will  probably 
mean  that  the  patient  will  present  at  some  future  time  with  an 
acute  alveolar  abscess.  The  most  thorough  investigation  should 
be  made  of  every  indication  that  a  pulp  may  be  dead  or  dying. 
On  board  a  steamer  crossing  the  Atlantic,  the  ship's  physi- 
cian asked  me  to  see  a  patient.  The  gentleman  had  come  aboard 
seemingly  well,  but  had  developed  a  pericementitis,  which  was 
running  rapidly  into  a  suppurative  period,  assuring  an  acute 
alveolar  abscess  within  a  few  hours.  The  pain  was  already 
very  severe  and,  as  there  was  no  possibility  of  finding  instru- 
ments for  the  rational  treatment  of  this,  I  advised  him  to  lose 
the  tooth.  There  were  several  pair  of  forceps  on  board,  and  I 
removed  the  tooth.  I  should  not  have  thought  of  removing  this 
tooth  if  the  case  had  been  in  my  own  oflfice.  This  gentleman  had 
visited  his  dentist  a  few  days  before  leaving  home,  and  it  had 
been  discovered  that  the  pulp  of  this  tooth  was  dead,  but  the 
dentist  told  him  that  he  would  let  it  go  until  the  patient  returned 
from  this  trip,  which  would  be  within  a  few  weeks.  This  was 
the  result. 


362  SPECIAL    DENTAL   PATHOLOGY. 


CHRONIC  ALVEOLAR  ABSCESS. 

ILLUSTRATION'S:    FIGURES  430-4G0. 

Etiology. 

THE  termination  of  the  acute  form  of  alveolar  abscess  with 
the  chronic  form  immediately  following,  and  persisting,  is 
one  of  the  marked  characteristics  of  the  disease.  My  observa- 
tions indicate  that,  unless  the  dead  pulp  is  promptly  removed 
after  the  subsidence  of  the  acute  stage,  the  chronic  form  follows 
in  as  many  as  98  per  cent  of  cases ;  in  other  words,  for  an  alveo- 
lar abscess  to  get  well  without  passing  into  the  chronic  form, 
unless  the  pulp  is  removed,  is  the  exception  to  the  very  general 
rule.  However,  the  soreness  usually  disappears  after  a  short 
time,  so  that  the  tooth  may  again  be  used  in  mastication  without 
discomfort. 

While  the  development  of  the  chronic  alveolar  abscess  is 
generally  a  sequel  of  an  acute  abscess,  the  acute  abscess  should 
not  be  considered  so  much  the  direct  cause  of  the  chronic  abscess 
as  is  the  dead  pulp.  If  the  acute  abscess  receives  prompt  and 
thorough  treatment,  and  the  dead  pulp  is  removed  from  the 
tooth  and  a  good  root  filling  made,  a  chronic  abscess  does  not 
develop  as  the  rule.  There  are  three  principal  causes  of  the 
development  of  the  chronic  abscess:  (1)  Infection  through  the 
root  canal ;  from  a  dead  pulp  which  may  remain  after  an  acute 
abscess,  or  which  may  cause  a  chronic  abscess  without  the  inter- 
vention of  the  acute  form;  or  following  imperfect  technic  in 
connection  with  the  treatment  of  the  canal;  (2)  Destruction  of 
the  apical  fibers  of  the  peridental  membrane  by  an  acute  abscess ; 
(3)  Destruction  of  the  apical  fibers  of  the  peridental  membrane 
by  strong  antiseptics  placed  in  the  root  canal. 

In  tests  of  the  power  of  the  bite  with  the  gnathodyna- 
mometer  in  a  large  number  of  cases,  most  patients  will  stop  short 
of  the  pressure  upon  these  teeth  which  will  be  exerted  upon  the 
other  teeth,  showing  such  teeth  to  be  lame,  although  they  may  not 
have  noticed  this  difference  in  the  ordinary  use  of  the  teeth. 
This  lameness  shown  by  the  gnathodynamometer  will  usually  be 
found  to  some  degree  in  all  cases  in  which  chronic  alveolar 
abscess  has  healed  permanently.     In  practically  all  such,  the 


Fig.  430. 


Fig.  431. 


Fw..  ■\:\-2. 


Figs.  430,  431,  432.     Lowim-  jjiu    ot' 
Oregon,   showing   ilcstnictioii  of   Ixnir   hv 
In  Figure  430,  the  ojieu   pnlji  t'h.-uiilx'rs 
Figures  431  and  4312  tlie  c'nilii's  in  the  \> 
injury  which  nceurs. 

*33 


■A  Fl;it  llfiiil  Indian  rruni  Coiundiia  Hiver. 
.•il\('i>l:ir  abscesses  from  Itotli  Hrst  molars, 
if  Ixitli  of  thi'sc  teeth  ni:iy  lie  seen  and  in 
,ne  ;ili(int   the  (list;il   runts  are  ty|iical  of  tiie 


Fig.  -iliS. 


Fig.  4;i4. 


Fig.  4.35. 


Fjg.   i'M 


Figs.  433  to  437.  Radiographs  which  emphasize  the  necessity  of  careful  diag- 
nosis. 

Figs.  433,  434.  Eadiographs  of  a  case  of  alveolar  abscess.  Figure  433  shows 
the  condition  when  the  patient  first  presented.  It  looks  as  though  both  bicuspids 
might  be  involved.  However,  the  pulp  of  the  second  bicuspid  was  tested  and  found 
to  be  alive.  The  first  bicuspid  was  extracted.  Figure  434  shows  the  condition  a 
year  later.     The  pulp  of  the  second  bicuspid  remained  vital. 

Fig.  43.').  In  this  radiograph  the  mental  foramen  is  shown  close  to  the  roots  of 
the  lower  bicuspids.  There  were  four  blind  abscesses  in  this  patient's  mouth,  and  at 
first  glance  one  might  mistake  the  mental  foramen  for  an  abscess.  In  view  of  the 
fact  that  the  second  bicuspid  is  supporting  one  end  of  a  bridge  and  the  root  canal  has 
not  been  filled,  an  abscess  from  this  tooth  might  be  expected. 

Figs.  436,  437.  The  radiograph  shown  in  Figure  43G  was  taken  for  a  rhini- 
ologist  in  an  examination  of  the  maxillary  sinus,  and  the  first  molar  was  ordered 
extracted,  with  the  belief  that  the  dark  area  above  it  was  an  alveolar  abscess.  The 
pulps  were  found  to  Ije  alive  in  the  second  bicuspid  and  first  and  second  molars,  and 
another  radiograph  was  ordered  taken  at  a  different  angle.  In  this  one  the  "  abscess  " 
does  not  appear. 


CHRONIC    ALVEOLAR    ABSCESS.  363 

peridental  membrane  about  the  apex  of  the  root  is  never  as 
strong  as  before.  The  ^nathodvnamometer  is  shown  in  Figure 
102. 

Pathological  changes. 

Destruction  of  the  periapical  tissues.  It  must  be  said  of 
the  fibers  of  the  peridental  membrane  attached  to  the  apex  of  the 
root  that  they  show  a  very  persistent  vitality.  In  the  beginning 
of  acute  alveolar  abscess,  it  would  seem  that  these  fibers  would 
be  destroyed  in  much  greater  proportion  than  the  facts  indicate ; 
generally,  they  are  not  destroyed  by  the  inflammation  in  the 
acute  form  of  alveolar  abscesses.  They  seem  to  take  little  part 
in  this  process.  The  bone  is  quickly  absorbed ;  the  pus  seems  to 
seek  the  cancellous  portion  of  the  bone  which  is  near  by  and  the 
pus  cavity  is  fonned  in  this  bone.  Very  little  pus  remains 
among  the  fibers  of  the  peridental  membrane,  which  have  been 
in  a  degree  loosened  from  their  attachment.  It  is  largely  for 
the  reason  that  the  abscessed  cavity  is  transferred  to  the  cancel- 
lous portion  of  the  bone  surrounding  the  end  of  the  root  that 
these  fibers  escape  destruction.  I  think  this  will  be  seen  by 
every  one  who  examines  many  radiographs  showing  pus  cavities. 

In  those  cases  in  which  the  abscess  cavity  is  not  well  drained 
during  the  acute  stage,  there  is,  naturally,  more  danger  of 
destruction  of  the  apical  fibers  of  the  peridental  membrane. 

//  dead  pulp  remains  in  tooth.  If  a  dead  pulp  remains  in  a 
tooth,  subsequent  to  an  acute  abscess,  a  clironic  abscess  will  be 
maintained  by  the  discharge  of  infectious  material  through  the 
apical  foramen.  If,  in  such  cases,  no  serious  injury  has  occurred 
to  the  peridental  membrane  up  to  the  time  when  the  case  pre- 
sents, the  proper  treatment  and  filling  of  the  root  canal  should 
effect  a  cure. 

If  periapical  tissues  destroyed  by  acute  abscess.  If  the 
acute  abscess  should  have  destroyed  the  apical  fibers  of  the  peri- 
dental membrane,  or,  if  from  the  continuous  subsequent  infec- 
tion from  the  root  canal,  these  fibers  are  destroyed,  the  abscess 
never  can  heal  so  long  as  that  area  of  detachment  remains. 

//  periapical  tissues  destroyed  by  druys.  If  drugs,  such  as 
phenol  and  some  preparations  including  formalin,  which  will 
destroy  tissue,  are  permitted  to  come  in  contact  with  the  apical 
fibers  of  the  peridental  membrane,  this  tissue  will  l)e  ]ienna- 
nently  destroyed  and  the  abscess  can  never  heal. 

Detachments  permanent  and,  maintain  chronicity.  There- 
fore, after  such  a  detachment  occurs,  the  case  continues  as  a 

33b 


364  speciaIj  dental  pathology. 

chronic  abscess,  even  though  the  pulp  may  be  removed  and  a 
good  root  filling  is  made.  Then  the  abscess  may  only  be  cured, 
either  by  cutting  off  the  end  of  the  root,  or  extracting  the  tooth, 
for  a  reattachment  to  such  an  area  of  cementum  is  impossible, 
as  we  have  seen  in  our  studies  of  the  detachments  occurring  in 
diseases  beginning  at  the  gingival  line.  It  is  for  this  reason 
that  such  abscesses  are  liable  to  discharge  continuously  and 
resist  all  efforts  for  a  cure. 

The  denuded  portion  of  the  cementum  in  this  case  acts  pre- 
cisely in  the  same  way  that  a  spicula  of  necrosed  bone  acts  in 
any  other  part  of  the  body.  A  recently  formed  chronic  abscess 
will  usually  heal  and  remain  well  after  the  cleaning  of  the  root 
canals,  and  the  filling  of  the  apex  of  the  root.  If,  however,  such 
an  abscess  has  persisted  for  several  years,  the  chances  for  a  cure 
are  diminished  in  proportion  to  the  time,  for  some  destruction  of 
the  peridental  membrane  over  the  end  of  the  root  practically 
always  occurs  sooner  or  later. 

The  maintenance  of  the  chronicity  of  such  cases  by  the 
denuded  cementum,  which  is  necessarily  pus-soaked,  is  no  new 
principle.  It  has  been  recognized  from  far  back  in  the  history 
of  the  development  of  patholog}^  that  a  spicula  of  pus-soaked 
necrotic  bone  remaining  in  the  tissues  will  keep  up  suppuration 
indefinitely.  Mr.  Lister,  in  his  struggle  to  render  a  true  account 
of  the  influence  of  micro-organisms  in  wounds,  makes  this  state- 
ment in  a  paper  he  presented  to  the  Royal  Society  of  London  in 
1867.*  It  will  be  noted  that  this  statement  was  made  before  the 
establishment  of  the  present  known  facts  of  the  production  of 
suppuration  by  micro-organisms.     It  runs  thus : 

''Further,  it  shows  that  the  mere  contact  of  a  foreign  body 
does  not  of  itself  stimulate  granulations  to  suppurate ;  whereas 
the  presence  of  decomposing  organic  matter  does.  These  truths 
are  even  more  strikingly  exemplified  by  the  fact  that  I  have 
elsewhere  recorded  (Lancet,  March  23,  1867)  that  a  piece  of 
dead  bone  free  from  decomposition  may  not  only  fail  to  induce 
the  granulations  around  it  to  suppurate,  but  may  actually  be 
a])sorbed  by  them;  whereas,  a  bit  of  dead  bone  soaked  with 
putrid  pus  infallibly  induces  suppuration  in  its  vicinity. ' ' 

This  applies  with  equal  force  to  cementum  which  has  lost  its 
soft  tissue  attachment  and  has  become  pus-soaked.  This  pus- 
soaked  cementum  can  not  be  loosened  from  its  attachment  to  the 
root  by  absorption,  for  neither  the  cementum,  nor  the  dentin, 

*  Epoch-Making  Contributions  to  Merlicine,  Surgery  and  the  Allied  Sciences,  by 
C.  N.  B.  Camac,  A.B.,  M.D.,  p.  13. 


CHRONIC    ALVEOLAR    ABSCESS.  365 

have  any  power  in  or  of  themselves  to  produce  an  absorption 
that  would  loosen  such  a  bit  of  necrosed  tisssue,  because  they 
have  no  circulation  of  red  blood,  nor  living  elements,  that  can 
perform  such  an  absorption.  Therefore,  it  becomes  a  perma- 
nent interference  with  the  healing  process. 

Classlfication.  The  several  forms  of  chronic  alveolar 
abscess  may  be  classified  as  follows :  (1)  Chronic  alveolar  abscess 
with  a  sinus;  (2)  chronic  alveolar  abscess  discharging  through 
the  root  canal ;  (3)  blind  alveolar  abscess,  from  which  there  is  no 
route  of  discharge,  the  contents  of  the  cavity  being  absorljed  by 
the  tissues;  (4)  chronic  alveolar  abscess  with  intermittent  or 
periodical  discharge. 

Chronic  abscess  with  sinus.  In  the  most  common  form  with 
a  sinus,  there  is  a  direct  route  for  the  discharge  of  pus,  extend- 
ing from  a  cavity  in  the  bone  about  the  apex  of  the  root,  through 
the  alveolar  process  and  soft  tissues  to  the  surface  of  the  gum 
in  a  position  immediately  over  the  root  of  the  tooth  which  has 
caused  the  abscess.  Less  frequently,  as  will  be  described  later, 
the  point  of  discharge  may  be  considerably  remote,  either  within 
the  mouth  or  upon  the  face  or  neck.  (See  Figures  404,  414,  415 
and  416.) 

Chronic  abscess  discharging  through  root  canal.  Those 
cases  in  which  the  discharge  is  through  the  root  canal  are  not 
different  from  those  having  a  sinus,  except  that  the  root  canal 
has  offered  the  route  of  least  resistance.  These  are  liable  at 
any  time  to  take  on  a  more  acute  form  by  the  plugging  of  the 
root  canal  with  food  debris.     (See  Figure  402.) 

Blind  abscess.  The  term  blind  alveolar  abscess  seems 
appropriate  as  descriptive  of  the  form  having  no  route  of  dis- 
charge. This  term  is  widely  known  and  used  by  the  profession, 
and  I  know  of  no  English  term  which  describes  it  better.  A  very 
limited  number  of  abscesses  of  this  type  are  amenable  to  treat- 
ment. Cysts  are  more  likely  to  be  formed  in  this  than  in  any 
other  class  of  cases.  It  is  probable  that  a  very  large  proportion 
of  these  have  more  or  less  characteristic  elements  of  cyst  forma- 
tion. Figures  438  to  441  are  radiographs  of  cases  showing  blind 
abscesses. 

Chronic  abscess  ivith  intermittent  discharge.  This  form  is 
practically  a  combination  of  the  other  forms.  An  abscess  with 
a  sinus  may  change  to  the  blind  form  by  the  closing  of  the  sinus ; 
it  may  then  discharge  again.  These  changes  may  occur  fre- 
quently.    Figure  442  is  an  illustration  of  an  abscess  of  this  iy^o. 

Variations  in  position  of  sinus  openings.     While  the  open- 


366  SPECIAL    DENTAL,    PATHOLOGY. 

ing  of  the  sinns  will  usually  be  immediately  over  the  root  of, the 
diseased  tooth,  this  is  not  always  the  case.  Sometimes,  espe- 
cially when  the  opening  is  on  the  face,  the  sinus  may  be  long  and 
tortuous.  I  recall  a  case  in  which  the  opening  was  through  the 
gum  exactly  over  the  root  of  a  lower  left  cuspid.  This  tooth 
gave  a  positive  response  to  heat,  as  did  the  other  front  teeth,  and 
as  both  bicuspids  and  the  first  and  second  molars  had  been 
extracted,  the  dentist  had  not  been  able  to  determine  the  cause 
of  the  abscess.  A  probe  followed  this  sinus  distally  to  the  root 
of  the  third  molar.  Occasionally  the  discharge  will  be  at  the 
gingival  line,  the  peridental  membrane  having  been  detached,  so 
as  to  form  a  sinus  alongside  the  root. 

Some  of  the  cases  are  more  obscure.  Formerly,  or  in  the 
early  history  of  my  own  practice,  I  saw  many  neglected  cases  in 
which  sores  had  persisted  for  a  long  time  upon  the  face,  or  even 
well  down  upon  the  neck,  from  this  cause.  The  pus  from  these 
abscesses  tends  to  gravitate  downward.  It  often  becomes  entan- 
gled under  the  fascia  or  along  the  course  of  the  fibers  of  muscles, 
and  follows  these.  In  many  cases  it  becomes  entangled  in  the 
platysma  muscle  and  follows  along  the  direction  of  its  fibers. 
It  is  not  uncommon  for  such  entangled  pus  to  break  out  upon 
the  skin  over  the  prominence  of  the  stemo-cleido-mastoid  muscle 
and  for  a  time  discharge  in  that  position;  or  it  may  pass  over 
the  stemo-cleido-mastoid  muscle,  and  still  following  the  fibers  of 
the  platysma  muscle,  discharge  at  the  position  of  the  clavicle. 
Occasionally  the  pus  will  pass  to  the  inner  side  of  the  clavicle 
and  enter  the  pleural  cavity  with  fatal  result. 

I  have  seen  cases  in  which  there  was  a  scar  upon  the  gum 
where  the  abscess  had  originally  discharged ;  another  scar  under 
the  angle  of  the  jaw,  another  along  the  line  of  the  sterno-cleido- 
mastoid  muscle,  and  a  fresh  sinus  opening  on  the  clavicle.  In 
this  way  they  leave  their  record,  ha\^ng  broken  out  here  and 
there  along  their  course,  discharging  at  one  place  for  a  time,  and 
then  gravitating  further  and  fomiing  a  new  place  of  discharge. 
Such  cases  are  now  very  rare.  The  change  is  the  result  of  the 
spread  of  information  in  regard  to  such  cases,  so  that  people  find 
relief  very  much  earlier  now  than  formerly. 

In  all  of  the  cases  in  the  lower  jaw,  the  pus  takes  a  course 
in  a  degree  similar  to  that  which  I  have  related.  Occasionally  it 
finds  an  exit  toward  the  lingual,  but  it  is  rare  for  it  to  burrow 
far.  From  the  lower  incisors,  the  discharge  may  pass  through 
the  lower  border  of  the  bone  and  make  its  exit  ])elow  the  chin. 
(See  Figures  415  and  416.) 


Fig.  43S. 


Fig.  439. 


rflta 


Fig.  440. 


Fig.  441. 


Figs.  438  to  441.     Four  radiographs  sliowin^   Miihl  ahscossos.     Fijjuros  43S  ami 

439  both  show  blind  abscossi's  from  botii  iiipsial  and  di,>>tal  roots  of  h)\v(>r  first  molars. 
In  Fifjfuro  440  tho  abscess  is  from  llic  root  of  the  ui)i)('r  bicns|ii<i.     in   l''ij,Mircs  43S  ami 

440  there  seems  to  liavo  been  no  attempt  at  root,  (iliiny;s.  In  I'^iyiire  441  there  is  a 
])lind  ai)Scess  from  the  lower  second  bieuspid.  also  an  abscess  from  tlie  lower  second 
molar,  and  liolos  w^rc  found  through  both  roots  near  the  bifurcation.     Wires  were  put 

tliroufjh    these  and   the   radiograph    was   taken    (n   cnnvii the    palii'nl    thai    the    tooth 

should  be  (extracted. 


Fig.  442. 


Fig.  442.  Photogritphs  of  plaster  model  of  a  case  of  chronic  abscess  with  inter- 
mittent discharge,  from  mesial  root  of  lower  first  molar.  A  sharp  steel  probe  was 
passed  into  the  sinus  and  it  was  found  that  there  was  an  extensive  destruction  of 
bone  about  the  root,  similar  lo  that  shown  in  Figure  431.     The  tooth  was  extracted. 


CHRONIC   ALVEOLAR   ABSCESS.  367 

From  an  upper  tooth,  if  the  discharge  is  on  the  face,  it  is 
usually  somewhere  along  the  malar  bone  or  under  the  malar 
prominence.  (See  Figure  411.)  A  very  few  cases  have  come 
under  my  observation  in  which  the  pus  has  become  entangled 
in  the  fibers  of  the  masseter  muscle  and  has  followed  down  to 
its  attachment  in  the  lower  jaw.  From  that  position  it  has 
usually  made  its  exit  about  the  angle  of  the  jaw ;  a  few  possibly 
becoming  entangled  from  that  point  in  the  fibers  of  the  platysma 
muscle,  or  other  muscles  and  going  farther  in  a  downward  direc- 
tion.    These  cases  are  very  uncommon. 

It  happens  also  that  abscesses  from  the  roots  of  the  upper 
molars,  and  bicuspids  as  well,  often  discharge  into  the  maxillary 
sinus,  producing  suppuration  of  its  mucous  membrane.  (See 
Figure  408.)  The  bone  covering  the  apices  of  the  roots  and 
forming  the  floor  of  the  maxillary  sinus  is  often  very  thin,  so 
that  pus  may  readily  penetrate  it.  There  is  little  doubt  but  a 
large  percentage  of  cases  of  suppuration  of  this  sinus  are  caused 
by  alveolar  abscesses.  A  specialist  in  diseases  of  the  nose  and 
throat  stated  to  me  recently  that  in  his  opinion  fully  eighty-five 
per  cent  of  maxillary  sinus  infections  resulted  from  alveolar 
abscesses.  In  other  cases,  particularly  from  the  incisors,  the 
discharge  may  be  into  the  nasal  cavity,  and  perhaps  be  difficult 
of  discovery.     (See  Figure  407.) 

The  discharge  from  an  abscess  from  the  root  of  an  incisor 
tooth  may  take  a  backward  course  and  follow  between  the 
mucous  membrane  and  the  bone,  and  make  its  exit  at  the  junc- 
tion of  the  hard  and  soft  palates.  I  am  persuaded  that  this 
discharge  may  occur  upon  the  upper  side  of  the  soft  palate,  but 
it  has  been  discovered  usually  upon  the  lower  side. 

Such  discharges  of  pus  from  chronic  alveolar  abscesses 
occur  in  exceptional  cases,  so  that  the  number  seen  by  any  one 
man  is  not  often  very  large.  I  have  had  the  opportunity  to  see 
unusual  numbers,  so  that  my  experience  has  been  very  much 
wider  than  that  of  the  majority  of  practitioners  of  dentistry. 
In  my  practice,  before  I  began  teaching,  I  was  in  continuous 
contact  with  physicians  and  surgeons  and  was  called  in  consulta- 
tion in  many  of  these  cases  by  a  tolerably  wide  range  of  medical 
men;  and  in  the  dental  school  clinic,  I  have  seen  most  of  the 
unusual  cases  which  have  presented  from  among  eight  tliousand 
to  thirteen  thousand  patients  per  year. 

Deposition  of  subperiosteal  bone.  In  cases  of  blind 
abscess,  there  often  is  more  or  less  enlargement  l)y  tlie  deposi- 
tion of  subperiosteal  bone  upon  the  surface,  while  the  bone  is 


368  SPECIAL.   DENTAL   PATHOLOGY. 

liol lowed  out  within.  This  enlargement  occurs  in  the  same  way 
that  subpeiiosteal  bone  —  the  involucrum  —  is  occasionally  built 
in  cases  of  necrosis.  In  cases  of  abscess  this  newly  formed  bone 
is  usually  so  thin  that  it  will  give  a  little  if  pressure  is  made  with 
the  finger  on  the  overlying  gum  tissue.  Many  of  these  are  over- 
looked until  there  is  quite  an  enlargement  from  the  cause  above 
mentioned. 

If  a  stiff,  sharp,  steel  probe  is  placed  upon  such  an  enlarge- 
ment of  the  bone  about  the  apex  of  the  root  and  considerable 
pressure  applied,  it  may  go  through  into  a  cavity,  developing 
the  fact  that  a  blind  abscess  of  some  size  exists.  In  some  of 
these  the  sharp  steel  probe  will  go  through  into  the  cavity  very 
easily,  while  in  others  it  will  require  heavj  pressure  to  push  it 
through,  owing  to  the  different  thicknesses  of  the  bone.  This 
bone  is  usually  quite  dense,  and  a  thick  shell  of  it  is  hard  to 
penetrate. 

Deposits  of  sekumal  calculus.  Whatever  portion  of  the 
cementum  is  denuded  of  its  peridental  membrane  may  receive 
a  deposit  of  serumal  calculus.  Such  a  deposit  occurs  under 
conditions  similar  to  those  under  which  serumal  calculus  is 
deposited  on  the  cementum  of  pus  pockets  resulting  from  inflam- 
mations of  the  gingivae.  The  denuded  cementum  absorbs  prod- 
ucts of  the  suppurative  process,  and  is  more  or  less  irritating  to 
the  adjacent  soft  tissue,  from  which  serum  is  exuded.  This 
carries  its  proportion  of  calco-globulin  whenever  there  is  any  in 
the  body  fluids,  and  a  deposit  occurs  on  the  root.  (See  Figures 
451  to  454.) 

Diagnosis. 

The  local  symptoms  of  chronic  alveolar  abscess  may  be  few, 
yet  a  diagnosis  is  usually  made  with  little  difficulty.  There  may 
be  a  history  of  an  acute  alveolar  abscess,  which  should  always 
lead  one  to  suspect  that  a  chronic  abscess  may  be  present. 

Pain.  There  may  be  no  complaint  of  pain  in  these  cases ; 
in  fact,  many  persons  doubtless  have  chronic  alveolar  abscesses 
for  years  without  being  conscious  of  their  presence.  The  patient 
may  complain  of  a  feeling  of  fulness  in  the  region  of  the  tooth, 
or  of  a  dull  aching  within  the  jaw  or  face  at  intervals.  There 
may  be  pain  almost  anywhere  on  the  same  side  as  the  diseased 
tooth,  which  may  be  associated  with  the  inflammation  about  the 
tooth. 

Tenderness  of  tooth.  The  patient  may  have  noticed  that 
the  tooth  was  lame,  or  tender  to  heavy  pressure.     The  tooth  may 


CHRONIC   ALVEOLAR   ABSCESS.  369 

have  been  periodically  sore  in  biting  upon  it.  In  a  good  many 
cases  the  tooth  will  do  its  usual  work  without  attracting  atten- 
tion, but  whenever  something  harder  than  usual  comes  upon  it  in 
chewing,  it  is  lame.  The  tooth  may  never  have  been  noticeably 
sore  or  lame,  but  the  patient  may  notice  a  difference  in  sensation 
when  the  diseased  tooth  and  several  others  in  the  neighborhood 
are  tapped  with  an  instrument,  or  if  lateral  pressure  is  made 
with  the  fingers ;  or  there  may  be  no  sign  whatever  of  lameness. 
The  lameness  is  likely  to  be  in  proportion  to  the  amount  of  tissue 
destroyed  about  the  apex. 

Absorption  of  bone  and  looseness  of  tooth.  If  the  abscess 
is  of  long  standing  and  some  bone  has  been  destroyed  about  the 
apex  of  the  root,  the  tooth  may  be  loose.  This  is  because  the 
fan-shaped  apical  fibers,  which  ordinarily  hold  the  apex  in  its 
normal  position,  have  been  destroyed.  By  a  digital  examination 
the  outline  of  the  root  may  be  made  out,  it  being  plain  that  the 
alveolar  process  is  missing. 

Pulp  of  tooth  dead  or  removed.  There  will,  as  a  rule,  be 
no  response  to  thermal  or  electrical  tests  for  the  vitality  of  the 
pulp  of  such  a  tooth.  Such  tests,  however,  are  not  decisive  in 
themselves.  Some  teeth,  especially  if  much  abraded,  give  no 
response,  although  the  pulp  may  be  vital.  In  teeth  having  more 
than  one  root,  the  portion  of  the  pulp  in  one  canal  may  be  dead, 
and  that  in  another  canal  may  retain  its  vitality  for  some  time 
and  there  might  be  a  response.  There  may  be  several  teeth  in 
the  neighborhood  from  which  pulps  have  been  removed,  so  that 
the  one  causing  the  abscess  can  not  be  differentiated  from  tlio 
others.  The  test  should  be  made,  however,  as  an  aid  in  diagnosis. 
A  tooth  containing  a  dead  pulp  is  likely  to  be  darker  in  color 
than  the  other  teeth;  in  fact,  any  tooth  from  which  the  \)u]p 
has  been  removed,  may  be  discolored.  In  those  cases  in  which 
the  pulps  of  undecayed  teeth  have  died  from  hyperemia  or  trau- 
matism, the  discoloration  may  be  the  only  sign  of  a  blind  abscess. 
Discharge  of  pus.  Pus  may  be  discharged  more  or  less 
continuously  from  a  sinus  about  the  apex  of  the  root  of  the  tooth. 
This  may  continue  through  half  a  lifetime,  or  more.  I  have 
observed  teeth  with  chronic  alveolar  al)scesses,  from  which  the 
pus  had  been  discharging  for  many  years,  although  the  teeth  had 
been  useful  every  day  in  mastication.  The  quantity  of  ]ius  dis- 
charged is  very  small;  often  not  more  than  a  droj)  every  few 
days.  As  has  been  mentioned,  the  discharge  may  be  intermit- 
tent, the  sinus  opening  and  closing  again  wlion  al)out  so  much 
pus  has  accumulated.     In  this  way  it  swells  and  breaks  every 


370  SPECIAL   DENTAX.   PATHOLOGY. 

few  days,  or  a  week  or  two  may  pass  between  these  discharges, 
during  which  time  the  abscess  seems  well  and  there  is  nothing 
but  a  scar  at  the  point  at  which  it  breaks. 

In  some  cases  in  which  there  is  a  discharge  eveiy  few  days, 
the  tissue  closing  between  times,  the  mucous  membrane  will  be 
pouched  out  and  will  form  an  excessive  granulation  through 
which  the  pus  escapes.  If  this  is  removed,  it  will  be  reformed. 
If  the  sinus  opening  is  on  the  face  or  neck,  the  discharge  may  be 
either  continuous  or  intermittent,  as  in  cases  discharging  upon 
the  gum. 

As  has  already  been  mentioned,  there  may  be  no  sinus  and 
the  pus  may  escape  through  the  root  canal  and  pulp  chamber 
into  the  mouth.  In  these  cases  also,  the  discharge  may  be  con- 
tinuous or  intermittent.  If  the  cavity  in  the  tooth  is  in  such  a 
position  that  it  may  be  packed  with  food,  the  escape  of  the  pus 
may  be  interfered  with  and  an  acute  abscess  may  develop. 

A  number  of  cases  presenting  as  blind  abscesses  are  evi- 
dently abscesses  from  which  pus  had  escaped  through  a  sinus 
for  a  time  and  later  the  sinus  closed,  yet  the  disease  had  contin- 
ued about  the  apex  of  the  root,  gradually  destroying  more  of  the 
periapical  tissues. 

In  a  number  of  cases,  particularly  those  in  which  the  original 
injury  is  caused  by  the  placing  of  powerful  antiseptics  in  the 
root  canal,  there  will  be  a  slight  discharge  of  clear  serum  through 
the  root  canal  into  the  pulp  chamber.  I  have  seen  a  discharge  of 
this  character  in  a  few  cases  in  which  I,  personally,  know  that  it 
was  not  caused  by  antiseptics,  but  such  cases  have  been  rare. 
In  the  majority  of  these  cases,  we  must  conclude  that  the  injury 
by  the  drug  has  preceded  the  infection.  In  some  cases  the  teeth 
may  become  persistently  painful,  as  well  as  sore  to  the  touch, 
and  may  remain  so  after  the  root  canal  treatment  has  been  com- 
pleted. Again  the  denuded  cementum  keeps  the  apical  tissues 
in  a  constant  state  of  irritation. 

I  remember  a  case  in  which  an  oculist  sent  me  a  patient  for 
examination,  with  the  statement  that  there  was  an  inflammation 
of  the  eyes  which  looked  something  like  trachoma  but  evidently 
was  not.  He  wanted  to  know  if  there  was  any  condition  about 
the  mouth  which  might  affect  the  eyes.  I  discovered  a  chronic 
abscess  over  the  root  of  an  upper  central  incisor  which  evidently 
discharged  intermittently.  The  tissues  were  swollen  at  the  time 
and  it  was  apparent  that  the  pus  would  be  discharged  within 
twenty-four  hours.  In  reply  to  a  question,  the  patient  said  it 
was  occasionally  painful  and  she  would  break  the  abscess  with 


CHRONIC    ALVEOLAR    ABSCESS.  371 

her  finger,  pressing  out  a  little  pus,  which  would  give  relief.  The 
abscess  shown  in  Figure  442  is  one  of  this  type. 

Suspecting  that  she  might  carry  the  infection  to  the  eyes  ou 
her  finger,  I  immediately  undertook  the  treatment  of  the  abscess. 
I  cleaned  the  root  canal  and  within  a  couple  of  days  the  pus 
discharge  ceased.  I  then  sent  her  back  to  the  oculist,  telling  him 
what  I  had  found  and  the  treatment  employed.  He  subsequently 
reported  that  the  eyes  were  practically  well  and  required  no 
further  treatment. 

Extent  to  which  cementum  is  denuded.  Examination 
WITH  STEEL  PROBE.  The  most  important  condition  to  be  deter- 
mined is  the  extent  to  which  the  cementum  has  been  denuded, 
for  this  indicates  the  treatment  to  be  employed.  It  is  usually 
not  difl&cult  to  discover  that  a  chronic  alveolar  abscess  exists; 
it  is  sometimes  difficult  and  generally  very  important  to  learn 
the  exact  condition  of  the  tissues  involved.  The  sharp,  stiff, 
steel  probe,  first  suggested  for  this  purpose  by  Dr.  Thomas 
L.  Gilmer,  is  by  far  the  most  important  single  means  to  be 
employed  for  this  purpose.  (See  Figure  465.)  The  probe  should 
be  passed  into  the  sinus,  and  it  will  usually  come  directly  in 
contact  with  the  denuded  end  of  the  root.  If  there  is  much  of 
a  cavity  in  the  bone,  the  contour  of  the  root  can  be  made  out; 
also  the  amount  of  bone  destroyed  may  be  determined.  This 
simple  examination  is  often  sufficient  to  a  full  diagnosis  and  to 
indicate  the  proper  treatment.  A  soft  probe  with  a  blunt  end 
is  of  little  service  as  compared  with  the  sharp  steel  prolie. 
Figures  431  and  432  give  a  good  showing  of  the  conditions  which 
may  be  felt  with  the  sharp  probe.  It  would  be  very  easy  to 
follow  the  contour  of  these  roots,  also  of  the  cavities  in  the  bone. 

Radiographs.  In  most  cases  of  chronic  alveolar  abscess,  no 
matter  which  form,  there  will  be  sufficient  destruction  of  bone 
about  the  apex  of  the  root  to  be  definitely  shown  by  a  good  radio- 
graph. The  use  of  the  radiograph  is  now  becoming  so  general, 
and  the  employment  of  small  films  for  use  in  the  mouth  give  so 
much  better  definition  of  the  teeth  and  maxillary  bones,  that  it 
should  be  the  rule  of  practice  to  have  radiographs  made  of  all 
cases  of  chronic  alveolar  abscess,  as  an  aid  in  making  a  complete 
diagnosis.  There  are,  of  course,  many  cases  in  whicli  the  other 
sjTnptoms,  and  particularly  the  findings  with  the  sharp  steel 
probe,  will  be  sufficient  to  indicate  that  the  tooth  should  be 
extracted.  However,  in  all  cases  in  which  the  effort  is  to  be 
made  to  save  such  a  tooth,  a  radiograph  should  be  made. 


372  SPECIAL   DENTAL   PATHOLOGY. 

Figures  438  to  441  and  443  to  450  are  radiographs  of  various 
types  of  abscesses.  Figures  433  to  437  are  shown  to  illustrate 
some  of  the  errors  which  might  be  made  in  reading  radiographs. 


CHRONIC    ALVEOLAR    ABSCESS.  373 


TREATMENT  OF  CHRONIC  ALVEOLAR  ABSCESS 

Historical. 

In  the  early  years  of  my  practice  of  dentistry  it  was  the 
habit  of  dentists  whom  I  knew  to  extract  all  teeth  presenting 
which  had  abscesses  at  their  roots,  the  impression  being  that 
such  cases  were  incurable.  I  very  soon  discovered  for  myself 
the  means  of  curing  many  of  these  abscesses  by  cleaning  the 
root  canals,  and  filling  the  apices  of  the  roots  of  the  teeth.  At 
first  I  filled  the  root  canals  with  gold,  and  the  treatment  was 
limited  for  some  years  to  those  teeth  more  readily  approached, 
as  the  front  teeth,  but  gradually  others  were  similarly  treated. 
No  instruments  for  this  purpose  could  be  obtained  from  the 
dealers.  I  had  to  make  them  myself.  I  succeeded  in  making 
very  many  of  these  teeth  useful  and  healthful,  so  far  as  I  could 
determine. 

At  that  time  I  supposed  that  this  process  was  original  with 
myself.  As  time  passed  and  my  acquaintance  with  dental  lit- 
erature became  wider,  I  discovered  that  others  had  done  the  same 
thing  before  me,  but  for  a  number  of  years  the  knowledge  of 
such  things  was  confined  to  a  comparatively  few  dentists,  and 
physicians  and  surgeons  had  no  Imowledge  of  it  at  all. 

Once  when  I  was  in  a  neighboring  city  I  was  shown  the 
results  of  a  surgical  operation  in  which  a  cancer  was  said 
to  have  been  removed  by  cutting  out  a  section  of  the  lower  jaw. 
I  quickly  showed  that  this  so-called  cancer  was  nothing  more 
than  an  alveolar  abscess,  presenting  a  rather  unsightly  api)ear- 
ance  upon  the  face,  and  might  have  been  cured  by  extracting  the 
tooth,  or  possibly  by  cleaning  the  root  canals  of  the  tooth  and 
filling  them. 

I  will  recite  one  other  case  which  occurred  twenty-odd  years 
ago.  It  serves  to  illustrate  the  lack  of  knowledge  of  these  cases, 
also  the  disadvantage  of  the  use  of  strong  antiseptics.  One 
evening,  while  I  was  at  work  in  my  laboratory,  a  physician,  wlio 
shared  his  office  with  a  dentist,  botli  of  whom  I  knew  well, 
entered  my  office  and  came  directly  to  my  laboratory.  Tie  told 
me  that  they  had  a  case  which  had  puzzled  both  the  dentist  and 
himself.     The  patient  had  a  sinus  on  the  neck,  a  little  under  the 

34 


374  SPECIAL    DENTAL   PATHOLOGY. 

point  of  the  chin,  and  they  could  not  discover  the  cause.  I  at 
once  asked  liini  if  they  had  examined  the  lower  incisors  care- 
fully. He  said  they  had  not.  I  told  him  to  look  for  a  lower 
incisor  which  was  darker  than  the  others,  and  if  there  was  such 
a  tooth  to  extract  it  at  once.  Accordingly,  the  next  day  an  exam- 
ination was  made,  and  such  a  tooth  was  found  and  extracted. 
On  examination  of  its  socket  for  necrosed  bone,  he  found  a  large 
opening  which  led  through  the  body  of  the  bone  to  the  site  of 
discharge  on  the  tissues  below.  An  ordinary  excavator  could  be 
passed  through  the  opening  from  inside  the  mouth  to  the  outside 
below  the  chin.  Vigorous  treatment  was  at  once  instituted. 
A  little  swab  was  wrapped  on  an  instrument,  this  was  moistened 
with  phenol  and  passed  through  the  opening.  This  was  repeated 
every  day  for  several  weeks,  but  the  abscess  refused  to  heal. 
Finally,  very  bad  weather  came  —  it  was  in  the  winter ;  a  storm 
prevented  the  patient  coming  in  for  about  ten  days,  as  she  lived 
several  miles  in  the  country,  and  to  the  surprise  of  these  gentle- 
men the  abscess  had  healed.  Had  they  left  the  case  alone  after 
extracting  the  tooth,  there  being  no  necrosed  bone,  the  sinus 
would  have  closed  within  a  few  days.  It  could  not  heal  while 
that  particular  treatment  was  continued. 

When  I  first  began  the  treatment  of  chronic  abscess  with  a 
sinus,  I  used  creasote  which  I  injected  through  the  apical  fora- 
men of  the  tooth  into  the  abscess,  when  I  could  do  so,  sometimes 
pumping  it  in  with  cotton  wrapped  on  a  broach.  In  this  way  I 
could  send  the  dnig  clear  through,  filling  the  abscess  in  pretty 
much  all  its  ramifications  until  the  drug  appeared  on  the  tissues 
on  the  outside. 

After  such  a  treatment  as  this,  an  abscess  of  recent  forma- 
tion —  that  is,  one  that  had  just  passed  from  the  acute  to  the 
chronic  form  —  would  almost  universally  get  well  with  a  single 
treatment. 

When  phenol  came  into  use,  this  was  substituted  for  the 
creasote  and  used  in  the  same  way,  and  was  pumped  through  the 
root  of  the  tooth  until  it  appeared  at  the  opening  of  the  abscess. 
This  was  also  generally  successful  in  the  class  of  cases  stated 
above,  one  treatment  being  sufficient. 

It  was  later  discovered  that  the  pumping  of  phenol  through 
into  the  abscessed  cavity  until  it  came  out  upon  the  surface  was 
unnecessary.  If  the  root  was  thoroughly  cleaned  and  kept  so 
by  the  use  of  an  antiseptic  in  the  root  canal,  such  an  abscess 
would  generally  get  well  without  other  treatment.  That  is  to 
say,  if  the  reinfection  through  the  canal  was  stopped,  the  tissues 


CHRONIC    ALVEOLAR    ABSCESS.  375 

in  and  of  themselves  took  up  and  destroyed  the  micro-organisms 
acting  to  produce  pus,  and  effected  a  cure  in  that  way. 

My  treatment  of  these  cases  was  gradually  simplified,  both 
as  to  the  number  and  frequency  of  the  treatments  and  the 
strength  of  the  drugs  used.  A  permanent  filling  was  made  at  the 
apex  of  the  root,  as  soon  as  the  pus  formation  ceased,  with  the 
belief  that  nothing  would  be  gained  by  further  treatment  through 
the  canal ;  that  the  continuation  of  the  abscess,  if  it  did  not  heal, 
would  be  due  to  injuries  which  had  occurred  to  the  tissues  about 
the  apex  of  the  root  and  which  would  not  be  benefited  by  root 
canal  medication.  The  object  was  to  prevent  future  ingress  of 
micro-organisms  through  the  root  canal.  This  general  plan  of 
treatment,  which  will  be  given  in  detail  in  the  following  pages, 
has  become  a  standardized  routine  procedure  which  may  l)e 
applied  to  practically  all  of  the  ordinary  cases  which  present. 

Treatment. 

After  having  made  a  clear  diagnosis  of  the  conditions  in 
chronic  alveolar  abscess,  the  course  of  treatment  should  be  deter- 
mined. As  has  been  mentioned,  the  most  important  thing  to 
learn,  previous  to  undertaking  treatment,  should  be  the  extent 
of  the  detachment  of  the  peridental  membrane  from  the  cemen- 
tum  about  the  apex  of  the  root.  If  this  tissue  has  not  been 
seriously  injured,  a  speedy  cure  may  be  expected.  On  the  find- 
ings in  the  examination,  it  should  be  decided  first  of  all,  whether 
the  tooth  should  be  extracted  at  once,  or  if  an  effort  should  be 
made  to  save  it.  If  much  of  the  root  is  denuded,  the  effort  to 
save  the  tooth  should  not  be  made  unless  the  amputation  of  the 
denuded  portion  of  the  apex  is  contemplated. 

Treatment  of  root  canal.  The  first  step  in  the  treatment 
should  be  directed  to  the  cleansing  and  subsequent  filling  of  tlie 
root  canal,  as  has  been  given  under  the  treatment  of  the  pulp. 
In  this  connection  I  will  only  mention  here  that  the  removal  of 
the  dead  pulp  and  the  thorough  sterilization  of  the  root  canal 
should  be  sufficient  to  cure  most  of  those  abscesses  which  are  m^t 
complicated  by  destruction  of  the  apical  fibers  of  the  peridental 
membrane.  If,  after  removing  the  dead  pulp,  a  mild  antiseptic 
dressing  has  remained  sealed  in  the  canal  for  a  week,  and  the 
discharge  of  pus  has  ceased,  the  root  should  be  filled  without 
further  delay.  Or,  if  there  is  some  improvement,  but  the  dis- 
charge has  not  entirely  ceased,  a  second  treatment  may  be 
sealed  in  for  a  week.  There  are  very  few  cases  in  which  I  would 
consider  further  treatment  of  the  canal  of  any  advantage,  and  I 


376  SPECIAL   DENTAXi   PATHOLOGY. 

would,  as  a  rule,  fill  the  root  canal  after  the  first  treatment,  or  in 
occasional  cases  after  the  second  treatment,  whether  the  sinus 
had  closed  or  not.  I  see  no  logical  reason  for  further  treatment 
of  the  canal.  The  failure  of  healing  is  due  to  conditions  outside 
tlie  root,  which  can  not  be  improved  by  treatment  of  the  canal. 
The  canal  should,  therefore,  be  filled,  and  subsequent  treatment, 
if  necessary,  directed  to  the  periapical  region  through  the  gum 
and  alveolar  process. 

When  sinus  does  not  heal.  If  the  case  does  not  heal  subse- 
quent to  the  filling  of  the  root  canal,  the  existing  sinus  should  be 
enlarged,  or  a  new  opening  through  the  gum  and  alveolar  process 
made,  in  order  that  the  end  of  the  root  may  be  resected.  Some- 
times there  may  be  small  spiculae  of  dead  bone  in  the  abscess 
cavity,  and  if  found,  these  should  be  removed.  If  these  meth- 
ods fail,  the  tooth  should  be  extracted. 

Cases  of  blind  abscess.  In  cases  of  blind  abscess,  in  which, 
on  account  of  the  constant  leakage  of  the  contents  of  the  abscess 
cavity  into  the  root  canal,  it  is  impossible  to  thoroughly  dry  the 
canal,  so  that  a  good  root  filling  can  be  made,  a  dressing  should 
be  sealed  in  the  canal  and  the  filling  of  the  root  delayed  until  the 
abscess  cavity  has  been  drained  by  an  opening  through  the  gum. 
There  will  then  be  no  difficult^"  in  drying  the  canal. 

In  order  to  be  able  to  reach  the  abscess  cavity  in  the  bone, 
novocain  may  be  injected,  and  a  curved  incision  from  one-half 
to  three-fourths  of  an  inch  long  should  be  made  through  the  soft 
tissues  over  the  root,  the  convexity  of  the  curve  being  toward 
the  crown  of  the  tooth.  The  tissue  on  the  concave  side  of  the 
cut  should  then  be  dissected  up  from  the  bone,  and  held  with  a 
small  retractor  or  other  instrument.  Then,  with  a  bibeveled 
drill  or  fissure  bur  in  the  engine,  the  opening  through  the  outer 
plate  of  bone  may  be  enlarged  until  there  is  free  access  to  the 
al)scess  cavity  within  the  bone.  If  the  case  is  a  blind  abscess,  the 
drill  is  used  to  cut  away  the  outer  plate  in  exactly  the  same  way. 
No  harm  is  done  in  cutting  away  a  considerable  amount  of  bone, 
so  long  as  the  drill  is  not  permitted  to  approach  too  near  the  root. 
The  greatest  care  should  be  taken  not  to  injure  the  peridental 
membrane. 

After  making  such  an  opening,  the  case  should  not  be 
allowed  to  heal  by  closure  of  the  superficial  tissues,  but  should 
be  kept  open  until  the  deeper  parts  have  healed.  A  small  strip 
of  gauze  may  be  introduced  to  keep  the  wound  open,  changing 
this  every  two  or  three  days ;  less  gauze  being  used  as  the  wound 
heals. 


^ 

M 

m^ 

ii 

I 

Fig.  443. 


Fig.  444. 


Fig.  445. 


Fig.  44(). 


Fig.  44  < 


Figs.  443  to  447.  Radiojjnipli.s  of  cases  of  chronic  alveolar  abscess.  In  both 
Fif^uros  443  and  444  tlio  roots  of  three  teeth  are  involved.  Figure  445  shows  a 
{i;ntta-])ercha  filling  in  a  hole  which  liad  been  drilled  tjirough  tlie  mesial  sid(>  of  the 
root  of  an  iipjx'r  lateral  incisor.  Tiiis  a|)i)ears  to  haxc  been  tli(>  cause  of  the  abscess 
in  this  case.  The  cus])i(l  root  has  been  exposed  by  th(>  abscess  cavity.  I'Mgure  44(? 
shows  a  cus])id  root,  with  very  little  attaclmient  left,  sujiporting  mir  rn.l  of  a  large 
l)ridge.  This  abscess  evidently  originated  from  tiie  lateral  incisor,  and  the  condition 
about  the  cus])id  root  should  h;i\c  iiciii  discovered  before  thi'  bridge  was  made.  Figure 
447  shows  an  abscess  from  an  upper  Literal  incisor.     This  root  was  resected. 

*34 


Fig.  448. 


Fig.  449. 


Fig.  450. 


Figs.  448,  449,  450.  Three  radiographs  showing  alveolar  abscesses.  In  Figure 
448  it  appears  that  a  crown  was  set  on  the  cuspid  without  treating  the  root  canal, 
or  at  least  without  filling  it.  In  Figure  449  the  principal  destruction  of  bone  has 
been  between  the  roots  of  a  lower  molar.  In  Figure  450  a  very  good  root  filling  is 
shown  in  an  upper  lateral  incisor.  The  bone  was  probably  destroyed  before  the 
treatment  of  the  canal  was  undertaken.  A  radiograph  at  that  time  would  have  given 
the  necessary  evidence  for  a  proper  diagnosis. 


Fig.  451. 


Fig.  452. 


Fig.  453. 


Fig.  454. 


Figs.  451,  452,  453  and  454.  Deposits  of  serumal  calculus  on  roots  in  cases  of 
chronic  alveolar  abscess.  The  deposit  on  the  side  of  the  root  in  Fifjure  452  was  in 
connection  witli  an  abscess  resultiiijf  from  a  liole  drilled  throufjli  the  root.  Specimens 
from  Northwestern  University  Dental  iMiiseuni.  In  connection  with  the  studies  of 
the  nature  of  the  deposit  of  calculus,  it  is  interesting  to  note  that  none  of  these 
positions  had  been  expo.sed  to  the  saliva,  except  possibly  in  Figure  452. 


FiG.  455. 


Pig.  456. 


Fig.  457, 


Fig.  458. 


Fig.  459. 


Fig.  460. 


ilGH.  455  TO  4(50.  Cases  of  loot  rcscotioii  in  treatment  of  ehronic  alveolar 
abscess.  In  each  instance  the  radiosrajilis  were  taken  at  least  a  vear  after  the 
operation.  Figures  455.  456,  459  and  460  are  from  cases  operated  by  l)r.  Thomas  L. 
fliim.-r.  Fi;ur,ires  457  and  45S  are  before  and  after  operation,  patient  of  Dr.  Arthur  D. 
Black.  It  will  bo  noticed  that  in  each  case  bone  has  been  built  into  the  space  for- 
merly occupied  l)y  the  end  of  the  root. 


CHRONIC    ALVEOLAR    ABSCESS.  377 

This  in  brief  constitutes  the  routine  treatment  of  the  chronic 
alveolar  abscess.  A  treatment  which  is  so  uniformly  successful, 
when  success  is  possible,  that  it  may  be  followed  with  the  expec- 
tation of  good  results,  in  practically  all  cases  in  which  the  apex 
of  the  root  is  not  denuded. 

Practice  in  vogue  should  be  discontinued.  The  practice 
in  vogue  for  so  many  years  of  treating  these  cases,  first  with 
this  drug  and  then  with  that,  without  having  made  careful  exam- 
ination of  the  conditions,  should  be  entirely  discontinued.  The 
extent  to  which  the  peridental  membrane  has  been  detached 
should  be  determined  first.  In  cases  in  which  there  is  any  rea- 
sonable doubt  as  to  the  existing  conditions,  generally  one  simple 
test  treatment  should  be  made  to  learn  whether  or  not  the  case  is 
complicated  by  the  denudation  of  the  cementum.  It  is  useless  to 
follow  this  up  with  a  varied  assortment  of  drugs  with  the  hope 
of  finding  something  that  will  cure.  Strong  antiseptics  may 
inhibit  pus  formation,  but  they  at  the  same  time  so  lower  the 
vitality  of  the  tissues  that  the  discharge  from  such  cases  will  be 
renewed  later.  One  who  makes  records  of  such  cases  will  find 
this  to  be  true.  The  regular  routine  treatment  of  alveolar 
abscess  here  given  has  proven  dependable  throughout  many 
years  of  practice  in  which  cases  have  been  followed  by  careful 
records. 

The  basis  for  the  change  of  this  treatment  lies  in  this  fact: 
Whenever  a  strong  antiseptic  is  used  in  any  of  these  cavities,  the 
phagocytes,  which  follow  up  and  actively  destroy  micro-organ- 
isms that  may  be  in  the  tissues,  withdraw  and  cease  their  activity 
in  combating  the  infection.  In  fact,  the  vitality  of  all  of  the 
tissue  with  which  the  antiseptic  comes  in  contact  is  reduced. 
For  this  reason,  the  cure  of  the  abscess  is  much  slower  than  that 
which  occurs  with  the  simpler  treatment  above  detailed. 

Records  of  a  large  number  of  recently  formed  abscesses 
show  that  very  few  failed  to  heal  when  caustics  were  not  used, 
whereas  in  cases  in  which  these  were  passed  freely  through  the 
apex  of  the  root,  many  did  not  heal.  Subsequently  an  area  of 
detachment  about  the  apex  of  the  root  was  demonstrable  either 
by  the  probe  before  extracting,  or  by  examination  of  the  root 
after  extraction. 

These  discoveries  compelled  me  to  oppose  the  passing  of  the 
stronger  antiseptics  through  the  apical  foramen  in  the  treatment 
of  roots.  If  this  is  safeguarded,  almost  any  of  the  milder  anti- 
septics may  be  used  for  the  purpose  of  maintaining  asepsis  in 
the  root  canals  during  the  treatment  of  the  case.     I  think  the 


378  SPECIAL   DENTAL   PATHOLOGY. 

general  tendency  of  late  years,  among  the  men  who  think  most 
closely,  has  been  to  use  the  milder  form  of  treatment.  In  a 
pretty  widespread  experiment  in  the  clinic  of  Northwestern  Uni- 
versity Dental  School,  the  prohibition  of  the  use  of  strong  anti- 
septics in  abscessed  cavities  has  shown  a  very  marked  decrease 
in  the  number  of  cases  of  sore  teeth,  and  of  abscesses  that  failed 
to  heal.  This  subject  is  more  fully  discussed  in  the  consideration 
of  the  use  of  antiseptics.  It  still  stands,  however,  as  expressed 
above,  that  the  older  the  abscess,  the  greater  will  be  the  propor- 
tion which  fail  to  heal  because  of  the  detachment  of  the  mem- 
brane from  some  portion  of  the  apex  of  the  root. 

Eesection  of  roots.  In  those  cases  in  which  the  cementum 
at  the  end  of  the  root  is  denuded,  the  tooth  may  often  be  saved 
and  the  abscess  cured  by  cutting  off  the  end  of  the  root,  or,  to 
use  the  term  suggested  by  Dr.  Thomas  L.  Gilmer,  by  resecting 
the  root.  This  operation  should  be  confined  to  the  upper  inci- 
sors, cuspids,  buccal  roots  of  first  bicuspids,  and  buccal  roots  of 
the  upper  molars.  Resection  of  other  roots  is  contraindicated  by 
the  greater  depth  of  bone  which  must  be  penetrated,  making  the 
operation  more  difiicult,  and  the  results  have  generally  been 
unsatisfactory,  even  when  a  good  operation  has  been  performed. 

Technic.  The  technic  of  the  operation  is  simple.  Under 
local  anesthesia  an  incision  is  made  through  the  gum  as  pre- 
viously described.  The  bibeveled  drill  is  then  used  to  cut  awaj'' 
sufficient  bone  to  give  access  to  the  apex  of  the  root.  Except 
in  cases  of  blind  abscess,  it  will  generallj''  be  necessary  to  do  very 
little  cutting  in  the  bone,  as  the  labial  or  buccal  plate  will  usually 
have  been  destroyed  already.  AVhen  the  root  is  exposed  it  may 
be  cut  off  by  drilling  a  hole  through  the  root  and  then  cutting 
laterally  in  both  directions  from  this  hole  with  a  fissure  bur. 
The  fissure  bur  quickly  fills  with  the  cuttings,  and  is  objection- 
able on  this  account  for  drilling  the  hole.  There  is  no  clogging 
of  a  bibeveled  drill.  After  the  apex  of  the  root  is  removed, 
the  end  of  the  remaining  portion  should  be  made  smooth  and 
slightly  rounded. 

In  cases  in  which  only  a  very  little  of  the  apex  of  the  root  is 
denuded,  a  large  fissure  bur  may  be  used  to  trim  off  the  end, 
without  removing  a  definite  piece.  In  each  case,  all  that  is 
required  is  to  remove  the  denuded  portion,  and  leave  the  remain- 
ing end  smooth.  This  should  be  followed  by  irrigation  to 
remove  the  debris  and  cleanse  the  cavity,  packing  sometimes 
being  employed  to  permit  healing  from  the  deepest  part,  as  pre- 
\iously  described. 


CHRONIC    ALVEOLAR    ABSCESS.  379 

Possibilities  of  healing.  One  might  think  of  the  conditions 
presenting  as  to  the  healing  of  the  tissues  over  such  a  root  end, 
as  being  identical  with  those  of  a  pus  pocket  resulting  from  a 
detachment  of  the  peridental  membrane  beginning  at  the  gingi- 
val line,  in  case  all  of  the  pus-soaked  cementum  were  removed 
from  a  denuded  area,  but  the  two  are  not  quite  parallel.  In  the 
case  of  the  resected  root,  it  is  a  matter  of  a  few  days  at  most 
until  the  root  end  is  entirely  enclosed  within  the  tissues  and 
completely  shut  off  from  the  fluids  of  the  mouth,  so  that  a  rein- 
fection is  very  much  less  likely  to  occur. 

There  are  three  possibilities  of  healing:  (1)  In  the  absence 
of  infection  the  tissues  may  attach  themselves  to  the  root  end ; 
(2)  the  cementoblasts  from  the  sides  of  the  root  may  gradually 
build  new  cementum  over  the  end;  (3)  the  tissues  may  simply 
heal  over  the  root  end,  without  being  attached  to  it,  the  same 
as  they  might  heal  around  a  bullet.  It  is  my  opinion  that  this 
last  is  what  really  happens  in  the  large  majority  of  cases. 

It  should  be  stated  that  a  percentage  of  these  cases  do  not 
do  well.  The  root  end  causes  sufficient  irritation  to  keep  up  a 
slight  discharge  and  the  opening  through  the  gum  does  not 
entirely  heal.  Or,  if  it  does  heal,  the  irritation  causes  the  con- 
stant outpouring  of  slight  quantities  of  serum  and  a  pocket 
remains  about  the  root  end.  In  either  case  the  elements  for  the 
reproduction  of  the  chronic  abscess  are  present,  and  sooner  or 
later,  it  is  formed.  All  cases  in  which  roots  are  resected  should 
be  carefully  watched,  and  within  a  year  or  so  a  radiograph 
should  be  taken  to  learn  the  condition,  even  though  the  tissues 
look  to  be  all  right.  The  cases  which  do  not  succeed  can  he 
cured  by  extraction.  Figures  455  to  460  are  reproductions  of 
radiographs  in  cases  in  which  roots  were  resected.  These  wei-e 
taken  from  one  to  three  years  after  the  operation. 

Amputation  of  molar  roots.  When  a  chronic  abscess 
involves  but  one  root  of  a  molar,  the  diseased  root  only  may 
sometimes  be  amputated.  This  operation  is  more  often  indi- 
cated for  lingual  roots  of  upper  first  molars,  and  less  often  for 
either  root  of  a  lower  first  molar.  The  technic  of  the  ojiorntion 
has  already  been  given  in  connection  with  the  treatment  of  sup- 
purative pericementitis.  In  cases  of  abscess,  more  or  less  of  the 
peridental  membrane  remains  attached  between  the  abscess  and 
the  gingival  line,  so  that  the  position  of  the  bifurcation  of  the 
roots,  their  general  contour,  etc.,  is  not  so  easily  determined  as 
in  cases  of  suppurative  pericementitis.  (See  Figures  290  to 
293.) 


380  SPECIAX,    DENTAL    PATHOLOGY. 


NECROSIS  OF  THE  MAXILLA 

ILLUSTRATION'S:    FIGURES  461-463. 

NECROSIS  of  bone  is  defined  as  death  of  bone  en  masse. 
This  occurs  under  widely  different  conditions,  and  in  any 
part  of  the  body  in  which  there  is  bony  tissue.  An  inflammation 
involves  the  periosteum  covering  the  bone,  and  may  extend  to 
the  bony  tissue  itself,  establishing  an  osteitis.  Or  the  inflamma- 
tion may  begin  witliin  the  bone,  as  in  the  case  of  an  osteomyelitis 
in  a  long  bone,  or  as  alveolar  abscess  in  the  maxillary  bones,  and 
extend  to  the  periosteum  later.  During  this  inflammation  an 
exudate  is  thrown  out  which  becomes  coagulated,  and  renders 
the  central  portion  of  the  swelling  harder  than  the  surrounding 
tissues,  which  are  swollen. 

In  the  harder  central  portion  of  this  area,  there  is  stasis  of 
the  circulation ;  that  is,  the  blood  does  not  circulate  in  this  par- 
ticular portion  of  the  inflamed  area.  Whenever  this  stasis  is 
widespread,  and  long  continued,  and  especially  when  it  involves 
bone,  there  is  likely  to  be  death  of  the  part  of  bone  that  is 
involved,  because  of  the  lack  of  aerated  blood.  It  can  not  be 
thrown  off  immediately,  like  the  sloughing  of  parts  under  severe 
inflammation  and  stasis  in  soft  tissue,  but  remains  attached  to  the 
living  bone  for  a  time.  Such  amelioration  of  conditions  or  of 
the  inflammatory  processes  must  occur  as  will  permit  the  activity 
of  the  healthy  bone  immediately  in  conjunction  with  that  which 
is  dead.  ^\nien  this  has  occurred,  a  process  of  absorption  is  set 
up  in  the  healthy  bone  close  around  the  dead  portion,  by  which  it 
is  finally  loosened.  The  dead  piece  thus  exfoliated  is  called  a 
sequestrum.  (See  Figures  461  and  462.)  Then  the  dead  por- 
tion of  the  bone  may  be  removed,  sometimes  in  pieces,  and  some- 
times complete  in  a  single  mass.  After  the  complete  removal  of 
this  dead  portion,  there  is  usually  no  hindrance  to  the  healing 
process. 

In  most  cases  there  is  fairly  complete  restoration  of  the  bone 
removed.  In  a  case  in  which  teeth  are  lost  with  the  alveolar 
process,  the  alveolar  process,  as  such,  is  never  reformed,  and 
often  this  makes  quite  a  deformity  in  the  mouth  where  large 
pieces  of  bone  and  teeth  are  lost  from  necrosis. 


necrosis  of  maxilla.  381 

Etiology. 

Necrosis  of  the  maxillary  bones  frequently  occurs  as  a 
sequel  to  the  death  of  a  pulp  and  the  formation  of  an  alveolar 
abscess;  in  fact,  this  is  by  far  the  most  frequent  cause.  (See 
Figure  461.)  It  also  occurs  as  a  result  of  injury,  such  as  fist- 
blows,  falls,  kicks  of  animals,  etc.,  in  which  the  bone  may  be 
fractured.  Occasional  cases  of  necrosis  of  the  maxillary  bones 
occur  from  arsenical  poisoning,  the  arsenic  having  been  used  for 
devitalization  of  the  tooth's  pulp.  Most  such  cases  result  from 
the  placing  of  arsenic  in  a  tooth,  the  roots  of  which  are  not  fully 
formed,  the  apical  ends  being  so  large  that  the  pulp  does  not  die 
of  strangulation,  and  the  poison  involves  the  tissues  outside  the 
end  of  the  root.  Cases  also  occur  from  arsenic  insecurely  sealed 
in  teeth,  some  of  the  arsenic  escaping  and  coming  in  contact  with 
adjacent  tissues  and  subsequently  with  the  bone.  Formerly  in 
regions  in  which  persons  were  employed  in  the  handling  of  phos- 
phorus, as  in  match  factories,  there  were  many  cases  of  necrosis 
of  the  maxillary  bones,  due  to  this  poison.  Most  such  factories 
now  engage  the  services  of  dentists  to  care  for  the  mouths  of 
their  employees,  and  have  thus  reduced  the  number  of  cases  to 
a  very  few. 

Syphilis  should  also  be  mentioned  as  a  cause  of  necrosis  of 
the  maxillary  bones.  The  palatal  portions  of  the  maxillary 
bones  and  the  palate  bones  are  almost  as  frequently  involved 
in  sj^philitic  necrosis  as  are  the  nasal  bones ;  in  fact,  most  cases 
of  necrosis  occurring  in  the  palate  are  syphilitic.  In  persons 
having  syphilis,  necrosis  is  more  apt  to  occur  in  connection  with 
alveolar  abscess  than  in  nonsyphilitic  persons. 

Symptoms. 

The  symptoms  of  necrosis  may  be  those  of  an  acute  alveolar 
abscess,  plus  the  finding  of  necrosed  bone.  Therefore,  severe 
pain  and  swelling,  with  high  fever  and  rapid  pulse,  frequently 
mark  the  acute  stage.  In  the  more  typical  cases  of  necrosis  of 
the  maxillary  bones,  symptoms  usually  appear  which  distinguish 
the  case  as  one  of  necrosis,  without  an  examination  of  the  bone. 
The  discharge  of  pus  is  persistent,  it  frequently  wells  up  about 
the  necks  of  teeth  in  the  area  of  bone  involved.  The  pus  is  of  a 
thick  creamy  consistency,  and  has  a  very  foul  odor,  which  is,  of 
itself,  almost  sufficient  for  a  diagnosis.  The  teeth  in  the  area 
may  become  very  loose  and  often  fall  out,  or  may  be  removed 
with  the  fingers. 

If  a  sharp,  stiff,  steel  probe  be  passed  into  a  sinus  or  other 

36 


382  SPECIAL    DENTAL    PATHOLOGY. 

opening  to  the  bone  which  is  necrosed,  the  bone  will  be  found  to 
be  bard  and  rough,  often  being  honeycombed.  The  examina- 
tion with  this  probe  alone  is  sufficient  to  easily  make  a  differen- 
tial diagnosis  between  necrosis  and  chronic  osteitis,  the  latter 
being  very  soft. 

In  the  rise  and  progress  of  necrosis,  there  is  much  pain  and 
swelling,  as  the  general  rule;  yet  I  have  seen  cases  in  which  the 
pain  was  not  more  than  would  be  called  a  dull  pain  and  the  swell- 
ing was  not  great.  Inflammations  involving  bone  are  generally 
more  painful  than  inflammations  involving  soft  tissue.  After 
the  death  of  the  bone  and  the  beginning  of  the  subsidence  of  the 
inflammatory  process,  there  is  not  much  pain,  providing  good 
drainage  is  maintained.  Of  course,  in  all  of  these  cases  there 
is  more  or  less  inflammation  and  suppuration  during  the  entire 
time  from  the  death  of  the  bone  until  its  final  removal. 

In  those  cases  in  which  the  periosteum  is  held  away  from 
the  bone  for  a  time,  the  osteoblasts  may  build  a  layer  of  new 
bone  in  the  new  position  of  the  periosteum.  This  bone  is  called 
an  involucrum.  It  usually  forms  a  thin  shell,  which  will  give  a 
little  on  pressure.  This  serves  to  partially  enclose  the  dead  bone 
and  it  may  be  necessary  in  the  treatment  to  break  away  some  of 
this  newly  formed  bone.  (See  Figure  463.)  This  addition  of 
subperiosteal  bone  frequently  occurs  elsewhere  in  connection 
with  disease  of  the  bone,  or  where  an  abscess  exists  because  of 
the  bridging  over  and  enclosing  of  pieces  of  necrosed  bone.  It 
not  infrequently  happens  that  the  bones  of  the  leg  are  very  much 
enlarged  by  building  on  of  subperiosteal  bone  over  the  deceased 
parts,  thus  strengthening  the  bone.  When  a  portion  of  the  lower 
jaw  is  cut  away  by  disease,  leaving  the  remaining  portion  rather 
weak,  I  have  seen  a  plate  of  bone  built  out  in  the  floor  of  the 
mouth  reaching  almost  to  the  center,  impeding  the  movements 
of  the  tongue.  After  the  diseased  bone  had  been  separated  and 
later  replaced  with  new  bone,  this  plate  of  bone  which  had  grown 
out  to  strengthen  the  weakened  part  was  removed  by  absorption. 
Generally  these  buildings  of  subperiosteal  bone,  which  seem  to 
be  called  out  for  the  purpose  of  strengthening  the  weak  places, 
will  be  absorbed  after  a  time. 

Treatment  of  necrosis. 

The  treatment  of  necrosis  should  be:  First,  the  establish- 
ment and  maintenance  of  good  drainage;  second,  nonsurgical 
interference,  so  far  as  the  bone  is  concerned,  until  the  necrosed 
bone  has  been  separated  from  the  healthy  bone ;  third,  the  care  of 


NECROSIS    or    MAXILLiE.  383 

the  patient's  general  health  in  the  matter  of  diet,  exercise,  fresh 
air,  etc. 

It  should  be  remembered  that  the  loosening  of  the  seques- 
trum is  a  physiological  process  and  can  be  carried  on  only  by  the 
tissue  activities  in  the  neighborhood.  This  not  only  requires 
nonual  activity  of  the  tissues,  but  also  requires  time,  and  this 
will  be  long  or  short,  as  the  tissues  are  more  or  less  active. 
Local  medication  can  not  hurry  it,  and  will  generally  hinder  it. 
It  would  be  an  entirely  wrong  practice  to  make  any  attempt  to 
remove  dead  bone  before  it  had  been  separated,  because  it  is 
impossible  to  tell  where  the  line  of  demarcation  will  be  estab- 
lished, and  to  cut  beyond  into  the  healthy  bone  exposes  it  to  the 
products  of  suppuration  and  decomposition,  which  are  always 
present  wherever  there  is  necrosed  bone.  Such  an  operation 
may  result  not  only  in  the  loss  of  more  bone  by  necrosis,  but 
exposes  the  patient  to  the  danger  of  a  general  septicemia. 

Secuee  good  drainage.  The  most  essential  thing  in  the 
treatment  of  necrosis  is  the  establishment  and  maintenance  of 
good  drainage.  Incisions  should  be  made  either  inside  the 
mouth  or  outside,  or  both,  to  give  very  free  drainage.  It  is 
usually  necessary  to  maintain  drainage  for  a  number  of  weeks, 
and  some  form  of  drainage  tube  or  packing  may  be  required  for 
this  purpose.  Fenestrated  rubber  tubing  may  be  used  in  the 
more  extensive  cases,  or  packing  of  gutta-percha  tissue  or  gauze 
in  the  majority. 

Cleanliness.  What  has  alreadj^  been  said  regarding  irriga- 
tion for  alveolar  abscess  applies  to  cases  of  necrosis.  The  dis- 
charge must  be  unobstructed  and  the  wound  should  be  kept  as 
clean  as  may  be  done.  If  saprophitic  decompositions  of  pus 
occur,  it  is  an  indication  that  the  drainage  and  cleanliness  are 
insufficient.  Nothing  is  of  greater  importance  to  the  early  sepa- 
ration of  the  dead  bone,  and  to  the  patient's  general  ])hysical 
condition,  than  the  maintenance  of  cleanliness.  Antiseptics 
should  not  be  used  for  this  purpose,  for  the  reason  that  anti- 
septics strong  enough  to  counteract  the  activities  of  the  micro- 
organisms will  also  materially  limit  the  activity  of  the  tissues  of 
the  neighborhood,  and  do  harm  in  this  way.  This  treatment  will 
reduce  the  fever  and  the  swelling  and  thus  keep  the  ]iationt  rea- 
sonably comfortable.  Cleanliness  should  be  maintained  until 
the  necrosed  portion  of  the  bone  has  loosened  sufficiently  to  be 
removed.  Sometimes  this  will  be  a  very  tedious  process,  requir- 
ing several  weeks. 

Extract  loose  teeth.    Whenever  teeth  in  the  area  are  very 


384  SPECIAL   DENTAL   PATHOLOGY. 

loose  and  pus  is  discharging  about  their  necks,  they  should  be 
extracted.  During  the  period  of  irrigation,  frequent  examina- 
tions should  be  made  to  find  pieces  of  bone  which  may  have 
separated  and  each  piece  should  be  promptly  removed.  Often- 
times the  necrosed  bone  will  come  away  in  a  number  of  pieces 
at  different  times,  and  each  piece  removed  reduces  the  inflamma- 
tion and  the  discharge  of  pus.  A  sequestrum  will  often  be  loose, 
without  being  freely  movable.  A  stiff,  sharp  instrument,  such 
as  a  chisel,  may  be  held  firmly  against  the  necrosed  bone,  and  its 
mobility  tested.  If  it  has  only  very  slight  motion,  so  that  its 
removal  might  be  difficult,  a  few  more  days  may  be  allowed, 
when  it  will  usually  be  found  to  have  more  motion. 

Cathartics  and  anodynes.  During  the  acute  stage,  the 
same  general  treatment  may  be  employed  as  in  cases  of  acute 
alveolar  abscess.  Saline  cathartics  should  be  given,  a  hot  foot- 
bath before  retiring,  and  anodynes  if  necessary. 

Cases  of  necrosis,  in  which  the  patient's  general  physical 
condition  is  much  reduced,  are  best  cared  for  in  the  hospital, 
although  the  majority  do  not  require  hospital  service.  How- 
ever, the  general  health  should  be  looked  after  in  all  cases,  and 
it  is  sometimes  desirable  to  call  a  physician  in  consultation  for 
the  purpose.  A  soft  diet,  moderate  exercise  and  plenty  of  fresh 
air  should  be  prescribed. 

Removal  of  sequestra.  In  the  removal  of  large  sequestra, 
it  may  be  necessary  to  either  enlarge  the  opening  through  the 
soft  tissues,  or  to  break  the  dead  bone  into  several  small  pieces  to 
facilitate  its  removal.  In  cases  in  which  an  involucrum  has 
formed,  which  serves  to  partially  enclose  the  dead  bone,  it  is 
usually  necessary  to  break  away  at  least  a  part  of  the  newly 
formed  bone,  both  to  make  the  removal  of  the  sequestrum  easier, 
and  to  peiTQit  the  soft  tissues  to  close  in  and  thus  advance  the 
healing  of  the  wound.  If  this  shell  of  bone  is  left  as  formed,  it 
serves  to  maintain  a  cavity  in  the  tissues  for  a  time. 

With  the  removal  of  the  last  piec^  of  necrosed  bone,  the  case 
will  generally  heal  rapidly.  A  very  small  piece  of  dead  bone 
may,  in  some  instances,  be  sufficient  to  keep  up  a  suppuration  out 
of  all  proportion  to  the  extent  of  the  dead  tissue.  The  treat- 
ment after  the  removal  of  the  sequestnim  will  depend  much  upon 
the  conditions  in  the  case.  It  is  generally  best,  if  the  sequestrum 
has  been  large,  and  particularly  if  the  cavity  is  verj''  deep,  to 
pack  with  gauze  every  other  day  for  a  week  or  two.  The  pack- 
ing with  gauze  may  be  employed,  or  not,  according  to  the  posi- 
tions and  relations  of  the  parts. 


Fig.  4(51. 


Fk;.  4(]\.  Necrosis.  A  hiucr  liist  muliir  aii.l  ;i  l:ir>,'r  sc.|iics1  luiii  ithu.v.mI  l.y 
Dr  Tlioinas  L.  Gilmer.  Tho  cxpusnre  of  ihv  pulp  fluiiiibor  iiuiy  bo  soon  in  tlio  nj^lit- 
li.md   illnstralion.     Spedmon  from  I^ortliwostoni   Univorsity  Uontni  Musoum. 


*35 


Fig.  462. 


Fig.  462.  Necrosis.  Two  views  of  a  largo  soqiiestnim  from  the  lower  jaw, 
removed  by  Dr.  Thomas  L.  Gilmer  at  the  Oral  Siirfrery  Clinic,  Northwestern  Univer- 
sity Dental  School.     Specimen  from  Northwestern   University  Dental  Mnsenm. 


NECROSIS    OF    MAXILLiE.  385 

I  wish  to  accentuate  the  necessity  for  removing  every  piece 
of  necrosed  bone,  no  matter  how  small,  by  relating  this  case. 

A  man  was  brought  to  me  with  a  sore  in  the  tissues  below 
the  body  of  the  bone  of  the  lower  jaw.  It  was  stated  that  this 
had  been  suppurating  for  eight  years,  and  that  several  physi- 
cians and  surgeons  had  endeavored  to  cure  it  by  widening  the 
opening  in  the  jaw  and  curetting.  I  looked  the  case  over  care- 
fully, and  noticed  that  the  first  lower  molar  on  that  side  was 
missing.  The  patient  stated  that  after  some  years  of  trouble, 
a  dentist  had  removed  the  tooth,  saying  that  the  abscess  would 
get  well,  but  it  did  not.  I  noticed  in  examining  it  that  the  full 
space  of  the  first  molar  still  remained  between  the  second  bicus- 
pid and  second  molar.  This  aroused  my  suspicion  of  something 
wrong  in  the  space  formerly  occupied  by  this  first  molar. 

I  passed  a  soft  silver  probe  into  the  sinus,  and  found  an 
opening  into  the  bone  through  which  the  probe  penetrated  easily 
until  it  met  an  obstruction  at  about  the  position  of  the  inferior 
dental  canal.  By  bending  the  end  of  the  probe  a  little,  I  finally 
succeeded  in  passing  it  farther  into  an  opening  under  the  position 
of  the  first  molar,  which  had  been  removed.  By  several  efforts  I 
succeeded  in  pushing  the  probe  forward,  and  it  came  to  an 
obstruction  which,  when  the  distance  was  measured,  seemed  to  be 
only  a  little  under  the  tissues  covering  the  surface  of  the  bone  in 
the  former  position  of  the  first  molar. 

I  made  a  crucial  incision  in  the  gum  and  laid  aside  all  of  the 
central  portion  of  it  with  a  blunt  instrument.  Then  placing  a 
small,  sharp  chisel  against  the  bone,  I  directed  my  assistant  to 
strike  it  with  the  mallet.  At  the  first  blow  the  instrument  went 
through  into  a  cavity.  I  broke  off  the  bone  sufficiently  to  get  a 
good  entrance,  and  found  there  a  spiculum  of  necrosed  bone, 
which  formerly  was  the  septum  between  the  roots  of  the  first 
molar  which  had  been  removed. 

The  failure  to  look  for  this  and  get  it  out  when  the  tooth  was 
removed,  had  caused  the  continuance  of  the  sinus  upon  the  face 
for  so  many  years. 

The  discharge  of  pus  from  this  abscess  ceased  within  four 
days,  the  tissues  healed,  and  the  case  remained  well.  This 
patient  was  so  enraptured  over  this  success  in  the  treatment, 
that  he  practically  never  came  to  town  afterward  without  run- 
ning up  to  say  ** Thank  you." 

One  of  the  worst  cases  of  necrosis  of  the  maxillar^^  bones 
which  have  come  to  my  attention  was  that  of  a  man  of  about 
thirty-five  who  had  for  years  been  in  the  habit  of  trimming  his 

SSb 


386  SPECIAL    DENTAL   PATHOLOGY. 

fingernails  with  liis  incisor  teeth.  He  could  start  at  one  side  and 
by  a  series  of  bites  trim  an  even  piece  off  the  end  of  a  nail, 
almost  as  smoothly  as  this  could  be  done  with  a  pair  of  scissors. 
One  day  he  called  on  his  dentist,  Dr.  W.  B.  Young,  of  Jackson- 
ville, 111.,  complaining  that  his  upper  incisor  teeth  were  loose. 
On  examination.  Dr.  Young  found  these  teeth  very  loose,  and 
the  alveolar  process  necrosed ;  pus  was  being  discharged  at  the 
necks  of  all  four  incisors.  There  was  also  swelling  of  the  tissues 
farther  back  on  both  sides  of  the  mouth.  He  extracted  the  four 
incisors,  and  noticed  a  foreign  substance  alongside  the  root  of 
one  of  the  centrals.  This  proved  to  be  a  cutting  from  a  finger- 
nail, which  had  evidently  slipped  up  under  the  gingiva  as  it  was 
bitten  off.  This  apparently  was  the  cause  of  the  infection,  which 
spread  rapidly,  and  eventually  involved  all  of  the  alveolar  por- 
tion of  both  superior  maxillary  bones.  Pus  penetrated  both 
antra  and  was  also  discharging  about  the  necks  of  all  of  the 
remaining  teeth.  Dr.  Arthur  D.  Black  was  called  to  see  the  case, 
and  he  found  it  necessary  to  remove  all  of  the  remaining  upper 
teeth.  Several  sequestra  came  away  with  the  teeth,  including 
parts  of  the  floor  of  both  antra.  During  the  next  few  weeks 
additional  sequestra  were  removed.  The  case  finally  made  a 
good  recovery. 

ProphyLu\xis  against  necrosis. 

In  the  protection  of  patients  from  necrosis  of  bone,  emphasis 
should  be  placed  upon  the  statement  that  the  large  majority  of 
these  cases  in  the  maxillary  bones  occur  as  a  result  of  alveolar 
abscess  in  which  pus  is  confined  for  a  time  between  the  bone  and 
the  periosteum,  having  parted  the  periosteum  from  the  bone. 
(See  Figures  405,  406,  409  and  413.)  If  the  inflammation  is 
running  high  and  particularly  if  considerable  fever  is  occurring, 
the  danger  of  necrosis  of  bone  is  decidedly  increased,  and  there 
should  be  no  hesitation  or  delay  in  applying  the  treatment  that 
has  been  indicated;   that  is,  the  full,  free  discharge  of  the  pus. 

This  case  occurred  in  my  practice  a  number  of  years  ago. 
A  patient  presented  with  a  dead  pulp  in  an  upper  lateral  incisor. 
The  tooth  was  sore.  After  placing  a  dam  and  sterilizing  the 
field  of  operation,  I  opened  the  pulp  chamber,  and  with  the 
utmost  care,  cleaned  the  root  canals,  and  sealed  in  a  treatment 
with  gutta-percha.  I  impressed  the  patient  with  the  necessity 
of  returning  promptly  if  the  case  became  worse  after  this  treat- 
ment, telling  her  that  there  might  be  serious  consequences  from 
delav.     Such  caution  has  been  my  usual  custom  in  the  primary 


NECROSIS    OF    MAXILLA.  387 

treatment  of  cases  similar  to  this  one.  This  was  on  Saturday 
afternoon,  and  she  did  not  return  to  her  appointment  the  next 
week.  I  was  uneasy,  and  after  a  few  days,  not  hearing  from 
her,  I  wrote  a  note,  asking  her  to  report  to  me.  She  replied  that 
the  tooth  had  become  exceedingly  sore,  her  face  was  much 
swollen,  and  that  her  physician  said  she  had  erysipelas,  which 
he  was  treating.  I  again  wrote  her  to  see  me  as  soon  as  she  was 
able.  About  two  weeks  after  the  day  on  which  I  removed  the 
dead  pulp,  she  came  in  with  her  face  still  swollen.  I  then  found 
that  an  alveolar  abscess  had  developed  at  the  root  of  this  tooth 
and  had  formed  a  l)road,  flat  swelling,  extending  distally  along 
the  jaw,  and  that  the  bone  was  necrosed  for  a  corresponding 
distance,  but  was  not  yet  ready  for  exfoliation.  "When  exfolia- 
tion did  occur,  the  sequestrum  included  the  lateral  incisor,  cuspid 
and  the  two  bicuspids,  and  opened  into  the  maxillary  sinus. 
This  undoubtedly  would  all  have  been  avoided  by  prompt  treat- 
ment of  the  abscess. 

In  this  case  the  physician  did  not  recognize  the  real  cause 
of  the  swelling,  but  finding  the  face  very  much  reddened,  he  came 
to  the  conclusion  that  it  was  erysipelas,  and  the  abscess  received 
no  treatment. 

I  recall  a  case  of  a  young  man  of  twenty-two,  who  presented 
with  an  abscess  at  the  root  of  a  central  incisor.  The  pus  had 
burrowed  along  the  bone,  raising  the  periosteum  from  it,  and 
was  discharging  between  the  gingivse  and  the  teeth  throughout 
that  side  of  the  mouth  to  the  third  molar,  and  necrosis  of  bone 
had  become  established.  I  extracted  the  teeth  from  the  cen- 
tral incisor  to  the  third  molar,  and  removed  the  necrosed  bone, 
including  the  buccal  portion  of  the  alveolar  process,  and  a  jior- 
tion  of  the  floor  of  the  maxillary  sinus.  By  breaking  away 
some  of  the  lingual  portion  of  the  alveolar  process,  which  had 
not  necrosed,  I  brought  the  tissues  across  the  opening,  stitched 
them  together,  and  the  case  made  a  very  good  recovery.  In  a 
number  of  cases  in  which  necrosis  has  involved  the  floor  of  the 
maxillary  sinus,  I  have  drawn  the  tissues  together  over  the  ojien- 
ing  after  the  bone  has  been  removed,  and  generally  there  has 
been  no  future  inflammation  within  the  sinus.  I  sent  the  young 
man  to  another  dentist  to  have  a  plate  made  when  the  ease  was 
ready  for  it,  and  a  piece  was  so  adjusted  that  he  could  wear  it 
with  comfort;  but  still  it  was  a  fearful  loss,  caused  by  neglect 
of  the  proper  treatment  before  the  case  came  to  me. 


388  SPECIAIi  DENTAL   PATHOLOGY. 


CHRONIC  OSTEITIS  OF  THE  MAXILLA 

ILLUSTRATIONS:    FIGURES  464-465. 

CHRONIC  OSTEITIS*  may  be  defined  as  death  of  bone,  cell 
by  cell.  Chronic  osteitis  differs  so  widely  from  necrosis  of 
bone  that  it  must  be  considered  an  entirely  separate  disease. 
It  is  a  condition  of  inflammation  and  disintegration  which  is 
progressive  in  its  character,  involving  the  bone  in  absorption 
and  separation  of  its  parts,  in  which  we  have  a  soft  mass  that 
may  enclose  more  or  less  small  hard  particles  of  necrosed  bone. 
The  condition  of  the  progress  is  such  that  the  bone  is  disinte- 
grated cell  by  cell,  instead  of  being  destroyed  en  masse  as  in 
necrosis.  Chronic  osteitis  shows  a  very  decided  disposition  to 
continuous  slow  progress,  attacking  and  softening  the  bone  to 
which  it  makes  approach,  often  hollowing  out  the  cancellous  por- 
tions of  large  areas  of  bony  tissue.  This  portion  of  the  bone  is 
seemingly  preferred  by  this  process,  although  upon  occasion  it 
will  burrow  through  the  hardest  bone.  The  disease  is  generally 
marked  by  what  we  would  term  a  chronic  condition  in  its  whole 
progress. 

Etiology. 

The  cause  of  chronic  osteitis  is  a  peculiar  form  of  infection, 
probably  symbioticf.  The  spread  of  this  infection  to  the  adja- 
cent parts  is  progressive,  but  slow.    In  the  mouth,  chronic  osteitis 

*  In  dental  literature,  this  condition  has  been  commonly  referred  to  as  caries  of 
bone.  The  word  caries  was  formerly  applied  in  surgery  to  a  cellular  destruction  of 
bone  caused  by  tuberculosis,  actinomycosis  or  syphilis.  The  condition  of  the  maxillary 
bones  here  described  is  similar,  but  seems  not  to  result  from  the  causes  mentioned. 

f  The  growth  of  two  or  more  micro-organisms  together,  producing  different  results 
from  the  growth  of  any  one  alone. 

Among  the  micro-organisms  in  the  mouth  there  are  several  symbiotic  combina- 
tions with  accidental  organisms,  and  they  are  somewhat  frequent.  The  best  example 
is  perhaps  that  which  produces  green  stain,  which  is  seen  oftenest  on  children's  teeth, 
consequently  I  will  use  it  as  an  illustration.  If  a  pure  culture  of  caries  fungus  is 
planted  in  a  Petri  dish,  spreading  it  on  about  one-half  inch  of  surface,  and  after  this 
has  grown  about  two  days,  one  of  the  molds,  penicillium  glaucum  or  penicillium  nigre, 
is  planted  about  one-half  inch  or  so  from  the  caries  growth  in  four  places  around  it, 
this  will  grow  very  much  more  quickly  than  caries  fungus,  and  its  mycelium  will  run 
in  every  direction  in  the  sub-stratum.  Wherever  the  mycelium  crosses  the  caries  fungus 
a  cloud  will  appear,  and  as  more  of  them  cross,  the  cloud  will  increase  in  depth.  No 
such  cloud,  however  will  occur  if  the  plants  are  kept  separate.  The  cloud  results 
from  the  combination  of  these  growths. 

A  child,  who  has  some  obstruction  which  interferes  with  normal  breathing,  will 
not  breathe  well  when  sleeping  unless  the  mouth  is  open.    The  gingival  portion  of  the 


Fig.  403. 


Fig.  463.  A  boy  who  had  had  an  acute  alveolar  abscess  from  a  lower  first  molar 
which  resulted  in  an  extensive  necrosis.  After  the  dead  bono  was  separated,  a  piece 
nearly  two  inches  long  remained  within  the  tissues  for  a  numlior  of  months,  pus 
discharginjT  through  a  sinus  on  the  neck  Itelow  tlie  lower  horde-  of  the  bone.  The 
periosteum,  wiiicli  ii:id  been  lifteil  from  the  outer  plate  of  the  bone  by  the  abscess, 
formed  an  involucrum,  part  of  which  had  to  be  cut  away  in  removing  the  sequestrum. 
Tliis  picture  Avas  taken  before  the  oiieration.  The  ajjparent  swelling  of  the  left  side 
of  the  face  is  due  to  the  new  bone,  which  h(>ld  the  soft  tissues  in  this  position.  There 
was  really  very  little  iiill;iiinii;itii.ii  uf  the  overlying  tissiu'S  at  this  time.  Patient  of 
Dr.  Arthur  D.  Black. 


Fig.  464. 


C 


B 
Fig.  465. 


Fig.  464.  Eadiograph  of  an  extensive  case  of  chronic  osteitis,  patient  of  Dr. 
Joseph  Eisenstaedt.  In  this  ease  there  was  a  rim  of  alveolar  process  which  held  the 
teeth  firmly  in  place,  while  practically  all  of  both  superior  maxillary  bones  from 
midlength  of  the  roots  to  and  including  the  floor  of  the  nose,  as  far  backward  as  a 
lino  drawn  across  from  the  right  cuspid  to  the  left  second  bicuspid,  had  been  destroyed. 
The  radiograph  does  not  show  so  large  a  cavity,  as  the  full  thickness  of  the  bone 
Avas  not  destroyed  over  the  entire  area. 

Fig.  465.  a,  The  sharp,  stiff  steel  probe  first  suggested  by  Dr.  Thomas  L. 
Gilmer.  With  such  a  probe  one  can,  with  a  little  experience,  easily  differentiate  the 
onauKd  of  an  impacted  tooth,  the  root  of  a  tooth,  necrosed  bone,  or  the  softened  bone 
in  chronic  osteitis.  This  probe  should  be  used  to  explore  every  sinus  about  the 
mouth.     B,  A  soft,  blunt  end  silver  probe  for  following  tortuous  sinuses. 


CHRONIC    OSTEITIS   OF    THE    MAXILL.E,  389 

occurs  most  generally  as  a  sequel  of  blind  alveolar  abscess, 
although,  it  may  occur  following  other  forms  of  chronic  alveolar 
abscess. 

It  is  a  rather  curious  fact  that  chronic  osteitis  seldom  occurs 
in  the  lower  jaw,  and  most  frequently  in  the  incisor  region  in  the 
upper  jaw.  The  number  of  cases  which  have  occurred  about  the 
roots  of  upper  lateral  incisors  have  each  year  attracted  attention 
at  the  Oral  Surgery  Clinic  in  Northwestern  University  Dental 
School.  This  should  be  a  particular  warning  in  our  care  of  this 
tooth.  It  should  be  remembered  that  the  pulp  of  the  upper 
lateral  incisor  is  more  liable  to  hyperemia  and  inflammation,  on 
account  of  the  small  size  of  the  tooth,  and  on  account  of  the  fact 
that  the  pulp  is  larger  in  proportion  to  the  size  of  the  tooth  than 
in  the  upper  central  incisor.  Therefore,  the  pulp  of  the  lateral 
will  be  involved  earlier  by  caries  than  that  of  the  central  because 
there  is  much  less  dentin  to  be  penetrated.  It  is  doubtless  often 
exposed  by  caries  before  the  root  is  fully  formed.  Likewise,  it 
is  more  liable  to  be  exposed  in  cavity  preparation,  and  is  more 
likely  to  die  from  thermal  shock.  The  lateral  incisor  is  often 
late  in  its  development,  and  the  pulp  is  destroyed  and  the  root 
filled  before  the  apical  foramen  has  been  sufficiently  reduced  in 
size.  When  it  is  necessary  to  remove  the  pulp  from  this  tooth, 
errors  in  technic  are  liable  to  occur  on  account  of  the  small  size 
of  the  canal  and  the  frequency  with  which  the  end  of  the  root  is 
crooked.  All  of  these  things  play  a  part  in  causing  the  large 
number  of  abscesses  from  upper  lateral  incisors  and  greater 
care  should  be  exercised  to  prevent  them. 

Symptoms. 

There  is  practically  no  pain  and  very  slight,  if  any,  swelling 
in  cases  of  chronic  osteitis.  The  temperature  will  seldom  exceed 
one  degree  above  normal.  The  subjective  symptoms  are  so  slight 
that  cases  will  often  run  for  years  without  the  patient  being 
conscious  of  anything  wrong.  There  may  be  a  little  discolora- 
tion of  the  overlying  gum  tissue.  A  close  examination  may 
reveal  one  or  possibly  several  very  minute  sinuses,  about  the 
openings  of  which  there  may  be  little  rings  of  granulation  tissue. 


labial  surfaces  of  the  upper  incisors  will  be  kept  moist  by  the  saliva,  wliich  has  a 
bountiful  supply  of  caries  fungus  growing  in  it.  In  this,  these  molds  are  liable  to 
grow  during  the  night,  and  cause  a  little  bit  of  color.  This,  occurring  night  after 
night,  results  in  the  formation  of  the  green  stain  on  tlie  front  teeth. 

This  case  illustrates  what  is  known  as  symbiosis  —  two  organisms  which  happen 
to  grow  together,  and  which  produce  a  result  which  neither  will  produce  when  growing 
alone. 


390  SPECIAL    DENTAL    PATHOLOGY. 

The  openings  may  be  so  small  tliat  they  will  be  discovered  most 
readily  by  making  pressure  with  a  finger  on  the  gum  and  noting 
the  discharge  through  them. 

The  discharge  from  cases  of  chronic  osteitis  is  usually  very 
slight  in  amount,  and  of  a  pale  yellow  or  straw  color.  Unless 
contaminated  with  saprophytic  organisms  which  produce  decom- 
positions, there  is  little  or  no  odor.  The  pain  is  slight,  but  if 
there  is  a  considerable  area  of  bone  involved,  there  is  a  systemic 
influence  that  is  not  expressed  strongly  by  fever,  but  an  indiffer- 
ent depression,  which  is  probably  caused  by  the  absorption  of 
material  from  the  infected  area. 

In  Dr.  Thomas  L.  Gilmer's  book  of  lectures  on  Oral  Surgery, 
prepared  for  the  students  of  Northwestern  University  Dental 
School,  he  describes  a  case  in  which  a  man  nearly  seventy  years 
of  age  presented  with  a  small  sinus  over  an  upper  left  lateral 
incisor,  and  in  operating  on  the  case,  it  was  found  that  most  of 
the  maxillary  bone  on  that  side  had  been  destroyed  by  this 
disease.  It  was  necessary  to  remove  all  of  the  teeth  from  the 
central  incisor  to  the  third  molar,  and  the  floor  of  the  maxillary 
sinus  had  been  destroyed. 

Figure  464  is  from  radiographs  of  nn  extensive  case  involv- 
ing most  of  the  bone  of  the  anterior  portion  of  the  palate. 

If  a  small,  stiff,  sharp,  steel  probe  is  passed  into  a  sinus  it 
will  usually  pass  into  a  cavity  within  the  bone,  and  the  end  of 
the  root  of  the  tooth  will  be  felt  within  this  cavity.  The  probe 
may  be  passed  up  and  down  and  partly  around  the  root  to  deter- 
mine the  extent  to  wliich  it  has  been  denuded.  If  the  end  of  the 
probe  is  pressed  against  the  softened  bone,  it  will  easily  penetrate 
it.  The  feeling  is  about  the  same  as  if  the  probe  were  pressed 
into  a  piece  of  unvulcanized  rubber.  This  will  definitely  com- 
plete the  diagnosis.     Such  an  examination  is  usually  painless. 

AVhenever  there  is  uncertainty  as  to  the  extent  of  the 
affected  area,  a  radiograph  should  be  taken.  One  will  occasion- 
ally be  surprised  to  find  by  the  radiograph  that  the  condition  has 
involved  much  more  bone  than  was  expected  and  may  have 
denuded  parts  of  the  roots  of  several  teeth. 

Treatment. 

The  treatment  of  chronic  osteitis  is  surgical,  and  should  be 
radical.  The  area  should  be  opened  freely,  and  every  particle 
of  the  softened  bone  removed  until  good,  sound  bone  forms  all 
of  the  walls  of  the  cavity.  This  removal  is  accomplished  usually 
and  for  the  most  part  by  spoon-shaped  curettes,  or  large  burs  in 


CHRONIC    OSTEITIS    OF    THE    MAXILL.E.  391 

the  engine.     Then  the  cavity  should  be  irrigated  to  remove  the 
debris. 

Generally  when  all  of  the  softened  bone  is  removed,  the  case 
makes  a  good  recovery.  In  connection  with  the  removal  of  the 
softened  bone,  it  is  necessary  to  either  cut  off  the  end  of  the  root 
which  projects  into  the  cavity,  or  extract  the  tooth.  If  the  end 
of  the  root  is  to  be  cut  off,  the  root  should  be  filled  first.  In  the 
more  extensive  cases,  in  which  the  roots  of  a  number  of  teeth  are 
involved,  these  teeth  must  receive  similar  treatment.  I  should 
say  that  the  larger  the  number  of  teeth  involved,  the  less  success 
may  be  expected  in  saving  them  by  resecting  the  roots.  It  has 
usually  been  my  practice  to  attempt  to  save  teeth  by  resection  in 
cases  in  which  the  area  of  bone  involved  was  small  and  included 
but  one  tooth.  When  several  teeth  were  involved,  I  have  gener- 
ally extracted  them. 


392  SPECIAL   DENTAL.   PATHOLOGY. 


THE  EPITHELIAL  CELLS  OF  THE 

PERIDENTAL   MEMBRANE  IN  RELATION   TO 

INFLAMMATIONS  AND  CYST 

FORMATION. 

ILLUSTRATIONS:    FIGURES  466-476. 

IN  discussing  the  histological  structure  of  the  peridental  mem- 
brane, attention  was  called  to  the  chains  and  clusters  of 
epithelial  cells  which  are  found  lying  close  to  the  cementum,  and 
reference  was  made  to  the  possible  functions  of  these  cells. 

Certain  views  have  been  occasionally  expressed  in  our  lit- 
erature as  to  the  role  which  these  cells  play  in  the  pathology  of 
chronic  suppurative  pericementitis  and  cyst  formation.  Some 
writers  have  considered  them  a  predisposing  factor  in  perice- 
mental disease,  contending  that  these  epithelial  cells  are  derived 
from  the  cells  which  float  away  in  the  breaking  up  of  the  enamel 
organs,  and  that  as  such  they  are  in  a  condition  of  decadence. 
Others  regard  them  as  normal  to  the  tissue  and  having  the 
special  function  of  limiting  infections  by  encystment,  thus  classi- 
fying them  as  unusually  active  and  vigorous. 

It  is  not  very  difficult  for  one  who  will  spend  the  time  to 
follow  a  class  of  animals,  or  several  classes  of  animals  of  differ- 
ent ages,  through  the  period  of  scattering  of  the  enamel  organ 
epithelial  cells  to  the  time  of  their  complete  disappearance  by 
absorption.  Those  who  undertake  this  should  have  previously 
become  well  acquainted  with  the  histological  examination  of  the 
development  of  the  teeth  and  of  the  peridental  membranes.  As 
a  result  of  such  an  investigation,  one  will  come  to  the  conclusion 
that  the  enamel  organ  cells  are  in  nowise  related  to  the  epithelial 
strings  in  the  peridental  membrane.  In  following  the  epithelial 
strings  of  the  peridental  membrane  from  a  young  animal  to  an 
aged  animal,  they  become  less  abundant  as  the  peridental  mem- 
brane becomes  thinner  and  the  alveolar  process  hugs  more 
closely  about  the  roots  of  the  teeth,  but  they  are  still  found. 
Whatever  may  be  the  function  of  these  cells,  they  are  normal  to 
the  location,  because  they  are  always  present  in  both  man  and 
the  higher  animals.     These  cells  must,  as  a  whole,  be  regarded 


PERIDENTAL   EPITHELIUM    AND   CYST   FORMATION.  393 

as  glandular.  I  know  of  no  other  terai  to  apply  to  them, 
although  they  have  no  ducts  and  in  many  respects  are  out  of 
form  as  glands. 

When  I  first  came  upon  these  cells  and  had  cut  a  number 
of  sections  in  different  directions  in  order  to  get  a  good  idea  of 
them,  I  was  much  puzzled  to  know  what  they  were,  and  I  called 
them  lymphatics  in  my  first  writing  of  them  in  1886.  I  after- 
ward corrected  this  error.  I  know  of  no  other  place  in  man  or 
animal  where  epithelial  cells  are  placed  in  the  relation  to  each 
other  as  are  these  epithelial  cells  in  the  peridental  membrane. 
But  that  they  are  normal  to  the  peridental  membrane  is  shown 
by  the  fact  that  they  are  always  present. 

There  are  long  rows  of  these  cells  in  the  peridental  mem- 
brane, reaching  from  the  body  of  the  gingiva,  along  the  side  of 
the  root  toward  the  apex,  and  these  are  placed  frequently  about 
the  root.  There  are  branches  from  one  to  the  other  of  these 
rows,  and  there  are  loops  which  extend  out  from  near  the  cemen- 
tum  among  the  fibers  of  the  peridental  membrane.  (See  Figures 
112  to  116.)  By  cutting  a  number  of  sections  of  the  peridental 
membrane,  parallel  with  the  long  axis  of  the  tooth  and  gradu- 
ally approaching  the  root,  first  from  one  direction  and  then  from 
another;  as,  for  example,  a  first  series  approaching  the  labial 
surface,  a  second  series  approaching  the  mesial  surface,  a  third 
the  lingual,  and  a  fourth  the  distal,  we  will  get  an  idea  of  the 
arrangement  of  these  cells.  From  observations  of  such  sections 
of  a  number  of  teeth  I  have  made  a  drawing  to  illustrate  the 
location  of  these  cells  in  relation  to  the  root.  (See  Figure  4:66.) 
The  figure  is  compounded,  and  has  never  been  actually  seen,  but 
it  expresses  my  idea  of  the  distribution  of  these  cells.  Figures 
112  and  114  also  show  something  of  the  same  arrangement. 

In  my  study  of  these  tissues  I  found  one  case  in  which  these 
epithelial  cells  were  especially  invaded  by  micro-organisms,  but 
I  do  not  think  that  this  apparent  following  of  the  epithelial 
strings  by  micro-organisms  marks  anything  like  their  decadence, 
or  failure  in  vigor.  It  only  shows  that  there  are  certain 
micro-organisms  which  invade  them  in  preference  to  other  tis- 
sues, probably  for  some  chemotactic  reason  that  we  do  not  yet 
understand. 

The  fact  is  that  the  membrane  is  invaded  very  often  in  long 
lines,  not  reaching  widely  around  the  root,  but  progressing 
directly  toward  the  apex  of  the  root;    the  area  invaded  being 

86 


394  SPECIAL   DENTAL   PATHOLOGY. 

very  deep,  but  narrow.  This  is  a  factor  in  the  patholog}^  of  the 
peridental  membrane  of  great  importance,  and  while  I  have  not 
felt  very  free  to  express  the  opinion  that  these  lines  of  cells  were 
followed  by  the  invading  organisms,  I  have  not  been  able  to  rid 
myself  of  that  thought. 

It  is  not  my  intention  to  follow  out  microbic  invasions  espe- 
cially, but  I  may  here  express  the  belief  that  the  microbic  inva- 
sion is  secondary  to  such  local  injuries  to  the  gingivae  as  I  have 
described,  and  not  to  some  micro-organism  which  is  essentially 
peculiar  to  this  disease.  It  seems  probable  that  almost  any  pus- 
forming  micro-organism  would  readily  establish  itself  in  such  an 
area  of  inflamed  tissue. 

The  evidence  has  swung  away  from  the  idea  that  disease  of 
this  membrane  is  caused  by  systemic  conditions,  to  the  opposite 
view  that  the  so-called  rheumatic  and  many  other  inflammatory 
conditions  arise  from  foci  of  infection  in  the  mouth  or  elsewhere. 
The  relation  of  mouth  foci  to  these  conditions  will  be  considered 
under  a  separate  heading. 

Studies  by  German  histo-pathologists. 

German  investigators  have  recently  been  in  a  controversy 
over  this  group  of  cellular  elements  of  the  peridental  membrane. 
I  have  a  list  of  twenty-two  articles  written  by  sixteen  different 
observers,  most  of  whom  seem  to  have  made  fairly  complete 
personal  laboratory  studies  of  the  histology,  and  especially  of 
the  participation  of  this  system  of  cellular  elements  in  patho- 
logical conditions. 

This  discussion  has  taken  a  very  wide  range.  It  involves 
studies  of  the  characters  of  the  cells,  their  derivation,  their 
function,  and  their  action  in  pathological  conditions.  This  con- 
troversy must  result  in  a  much  more  accurate  knowledge  of  the 
peridental  membrane,  both  in  the  normal  condition  and  in  its 
pathological  changes. 

Such  studies  in  histo-pathology  should  be  made  in  perfectly 
fresh  tissue;  it  should  be  placed  in  the  fixative  solution  while 
the  cellular  elements  are  alive,  for  these  live  a  short  time  after 
the  death  of  the  animal  or  of  the  person.  In  this  study  we  must 
use  human  material. 

In  the  Monatzschrift  fuer  Zahnheilkunde,  for  November, 
1912,  Professor  Dr.  TIl  Dependorf,  of  Leipzig,  published  prac- 


!•  ic;    4ii(J. 


Fkj.  4(17. 


Via.  MiC).  Dniwiiij;-  iiiailc  to  illustrate  tlir  iMisitimi  of  tlic  f|iit  lirlial  string's  in 
tlir  |)cri(li'iital   iiii'iriluaiM'.      Sec  dt'scri  |)|  inn   in   Icxt,  |ia>;c    ll»;',. 

Fic.  4()7.  Px'f^iniiiiifr  cyst  toriiiii t ioii  sliowiii^r  central  ca\  itv  lined  by  cpitlicliuni. 
In  tlif  center  of  tlic  masses  of  eiiitiielinni  whicii  line  the  cavity  one  sees  tho  enlarged 
cells,  granular  and  \acii()lar.  Many  cells  seem  to  be  devoid  of  nuclei;  the  nuclei  of 
others  stain  poorly.  Specimen  jneiiared  in  author's  laboratory  l.y  Dr.  11.  A.  Potts. 
Photomicrograiili  by  Di'.  P.  B.  Noyes. 


*36 


Fig.  4()S. 


Fjg.  469. 


I"'i(;.  KJS.  ■■Section  tiir(inii;li  ii  [lail  of'  ;ni  ciiitliclial  oiniiuldiiia,  sluiwiii^'  l);ui(l-like 
strands  of  ejjitlieliiil  eells  among  fatty  deueiicratril  ami  isnlatcd  granulation  tissue. 
The  arrangement  simulates  an  atyi)iL-ai  epithelial  d(velci]inieiit.  in  tlie  center  is  an 
eiiitlieiiai  mass  (ejiithelglocke)  which  is  ijeginning  to  be  se])arated  from  tlie  graiuila- 
tion  tissue."  Reproduction  of  illustration  and  translation  of  description,  from  article 
Ijy  Dr.  Th.  Dependrrf,  referred  to  in  text. 

Fig.  469.  "Slightly  oblique  section  tlirimgh  the  up|)er  Jaw  of  an  adult.  Cysto- 
granuloma  with  lumen  which  contains  pus  and  tissue  tlebris.  Ei>ithelium  has  devel- 
ojied  into  and  C)nipletely  sunounded  the  focus.  To  the  left  of  th(>  cysto-granuloma 
is  a  softened  septic  focus  \vithout  an  epithelial  covering,  presenting  a  beginning  sinus 
which  is  making  its  w.ay  to  the  surface  of  the  mucous  membrane.  The  root  to  the 
left  is  not  in  rtdation  with  the  cysto-granuk.ma,  which  belongs  to  the  area  surrounding 
the  apex  of  the  neighboring  tooth.  Reproduction  of  illustration  and  translation  of 
description,  from  article  by  I)r.  Th.  Dependorf,  referred  to  in  text. 


Fk;.    171). 


Fig    470.     Boginninu  <-vst    lunnati...,   at   aiu-x   ..f   r.M.t    ..la    i.nl|.U'ss   loot!..      Om- 

is  a  prolificalion  of  f'l.itl.di.un.  In  tl.o  i-entcr  is  a  .-ioar  aroa  hncl  b  opitlu  lul 
celll  which  upon  tho  inrfac-o  ha  v.  h...-o,no  ,uito  stratili..!.  W.th.n  th.  f' -.us  .a  .- 
sulo  aro  «n,n.'  snli.l  .-inn.i.s  of  rpith-lial  .m.Hs.  Sponmon  pivpami  ...  author,  lab- 
orat...v  l.v   Dr.   il.  A.  i'ults.     Phulu.ni.-.K^.ai.h  l.y   V.  B.  Noycs. 


Fig.  471. 


Fig.  471.  Abscess  attached  to  apex  of  root  showing  dense  fibrous  tissue  capsule. 
In  the  center  is  a  mass  of  round  cells,  into  whicii  fibroblasts  and  new  blood  vessels 
are  growing  from  the  periphery.  A  few  giant  ceils  are  to  be  seen  in  the  younger 
fibrous  tissue.  See  text,  page  '.VM.  Specimen  prepared  in  author's  laboratory  by 
Dr.  II.  A.  Potts.     Photomicrugniph  by  Dr.  F.  B.  Noyes. 


■-:'~,rv?ssSs^^^? 


l''Ki.    j; 


Fig.  472.  f'yst  loniiatinn  in  iilvcoliiv  jihsccss,  most  of  tlic  c-ivitv  l)t'iiiti  lined  by 
ppithelial  cells.  Tlicrc  is  :i  well  <|"iiiic(|  (iluoiis  tissue  eajisiili'.  S|nrimen  prepared 
in  aiitlior's  lahoratory  liy  i>i-.  11.  A.  I'oMs.      I'hotomicrojirapli  l>y  l»r,   I'.  I'..  Noyes. 


"z.'^-smni^J 


:^ma[ 


Fus.   47o. 


Fig.  473.  Tissue  growing  into  apii-iil  foramen  of  jmlpless  tooth.  There  are 
many  round  cells,  fibroblasts  ami  new  hlooil  vessels  growing  inside  the  canal,  as  well 
as  formed  connective  tissue.  Specimen  prepared  in  author's  laboratory  by  Dr.  H.  A. 
Potts.     Photomicrograph  by  Dr.  F.  B.  S'oyes. 


wfj^WSflpp^? 


.-^--v, 


'A 


Fig.  474. 


Fig  474  Hijili  |Hi\vcr  i.f  cvst  wall  sliuwiii^  llic  .'iiil  lirlinl  liiiiiij;-.  Spri-iinni 
prei)arod  in  '  uutliui's  hlM,r;i1niy'  l.y  Dr  11.  A.  Tolls.  l'h,.t  ,mncTo^r,-:,ph  l.y  Dr. 
F.  B.  Novi's. 


Fig.  47G. 


Fig.  475.  Section  of  a  wall  of  a  largo  cyst,  showing  papillomatous  growth  within 
the  cyst  cavity,  the  whole  cavity  being  lined  by  epithelial  cells.  The  walls  are  fibrous 
and  contain  much  round  cell  infiltration  near  the  cyst  cavity,  while  the  outer  part  is 
dense  fibrous  tissue.  .Specimen  prepared  in  author's  laboratory  by  Dr.  H.  A.  Potts. 
Photomicrograph  by  Dr.  F.  B.  Noyes. 

Fig.  476.  High  power  of  cyst  wall  showing  the  epithelial  lining.  Specimen  pre- 
pared in  autlior's  laboratory  by  Dr.  H.  A.  Potts.  Photomicrograph  by  Dr.  F.  B. 
Noves. 


PERIDENTAL    EPITHELIUM    AND    CYST    FORMATION.  395 

tically  a  complete  review  of  this  work  up  to  that  tune.*  A  trans- 
lation of  this  article  was  made  at  the  time  by  Dr.  Anna  A. 
Oppermann.f  It  is  not  my  intention  in  the  present  writing  to 
do  more  than  call  attention  to  the  studies  which  have  been  made 
and  to  give  the  principal  views  expressed.  My  recent  investiga- 
tions of  these  cells  have  not  progressed  far  enough  to  justify  a 
complete  presentation  of  the  subject. 

The  review  by  Dr.  Dependorf  showed  a  wide  range  in  the 
views  of  the  various  writers.  There  is  a  contention  that  the 
strings  of  epithelial  cells  found  in  the  membrane  are  the  remains 
of  the  broken-up  epithelia  of  the  enamel  organs.  A  number  of 
investigators  speak  of  these  cells  as  epithelial  remains.  Others 
take  the  view  that  these  cells  are  normal  to  the  peridental  mem- 
brane, and  are  not  in  any  sense  whatever  remains  from  the 
breaking  up  of  the  epithelia  of  the  enamel  organs.  Some  of 
these  observers  seem  to  have  followed  this  point  carefully  from 
the  child  at  term  for  several  years,  and  declare  that  the 
scattered  epithelia  from  the  enamel  organs  break  up  more  and 
more,  are  absorbed  and  disappear  completely ;  that  the  epithelial 
strings  are  normal  to  the  peridental  membrane  and  bear  no 
relation  to  the  epithelial  cells  scattering  away  from  the  enamel 
organs  of  either  the  deciduous  or  permanent  teeth.  I  have  made 
very  thorough  studies  of  these  cells,  and  this  latter  view  agrees 
perfectly  with  my  own.  This  is  the  view  given  prominence  by 
Dr.  Dependorf.  These  cells  are  always  present.  They  differ 
in  number  and  in  prominence  in  different  animals,  but  are  never 
absent.  They  are  most  abundant  in  the  herbivora  and  omni- 
vora ;   least  in  the  carnivora. 

Cyst  formation. 

The  activities  of  these  epithelial  cells  in  pathological  condi- 
tions are  the  most  interesting  feature  of  the  studies  referred  to 
above.  They  place  them  in  the  principal  role  in  the  formation 
of  cysts  in  the  peridental  membrane,  and  in  the  tissues  of  the 
neighborhood.  There  are  thirty-one  illustrations  in  the  article 
by  Dr.  Dependorf,  of  which  I  reproduce  two.  (See  Figures  468 
and  469.)  One  shows  a  complete  encystment  of  an  infected  area, 
the  other  a  section  of  an  encysting  wall. 

The  word  cyst  is  from  the  same  derivation  as  our  more 
common  word  cistern,  a  space  walled  off  to  catch  and  store  rain- 

*  Zur  Pathogenese  der  Zahnwiirzelzystem.    Deutsche  Monatzschrift  fiir  Ziihiiheil- 
kunde,  1912,  p.  809. 

f  Northwestern  Dental  .Toiirnal,  Vol.  X,  p.  7.3;    Vol.  XT,  p.  9. 


396  SPECIAL   DENTAL   PATHOLOGY. 

water.  In  the  pathological  sense,  a  cyst  is  a  space  which  con- 
tains a  fluid,  walled  off  by  a  membrane.  Cysts  may  result  from 
injuries  or  disease.  The  limiting  membrane  is  usually  epithe- 
lial, though  there  are  cysts  with  membranes  of  endothelium  of 
the  type  of  the  IjTuphatic  system.  These  serve  to  wall  off  por- 
tions of  tissue  which  have  been  injured.  In  the  skin  and  mucous 
membranes  injuries  often  occur  to  the  ducts  of  sebaceous  or 
other  glands,  causing  the  retention  of  the  secretion  by  the  closure 
of  the  duct.  T^e  fluid  contained  in  a  cyst  may  vary  from  a  thick, 
fatty  matter,  to  a  thin,  opalescent  fluid. 

In  order  to  have  a  cyst,  it  would  seem  that  epithelium  should 
form  the  limiting  membrane.  In  the  positions  I  have  just  men- 
tioned, the  epithelium  of  the  glands,  or  gland  ducts,  is  at  hand 
for  this  purpose.  In  the  fonnation  of  the  cysts  which  are  so 
frequent  in  the  peridental  membrane,  the  epithelium  composing 
the  epithelial  strings  and  clumps  of  cells  appears  to  play  a 
principal  role. 

In  case  of  an  inflammatory  movement,  there  is  at  once  a 
new  growth,  or  increased  growth,  in  these  epithelial  strings. 
If  there  is  in  the  neighborhood  a  group  of  cellular  elements 
which  are  unable  to  maintain  their  vitality,  they  are  hedged 
about  at  first  by  the  growth  of  these  epithelial  strings.  As  the 
area  of  seminecrotic  tissue  enlarges,  these  epithelial  strings 
broaden  into  sheets,  which  tend  to  surround  and  enclose  it. 
If  this  movement  of  the  tissues  is  complete,  the  area  will  also 
have  become  surrounded  by  connective  tissue  cells  outside  of  the 
epithelium.     This  constitutes  the  formation  of  a  cyst. 

As  a  cyst,  it  may  enlarge  and  wander  in  the  direction  of 
least  resistance,  usually  gathering  to  itself  more  fluid  contents. 
The  cyst  may  thus  assume  considerable  dimensions  and  may 
destroy  adjacent  tissues  by  the  pressure  resulting  from  its 
growth.  Or,  on  the  other  hand,  the  cyst  may  show  the  oppo- 
site tendency,  and  become  progressively  smaller  until  it  is 
obliterated. 

These  conditions  result  from  infection.  Chronic  alveolar 
abscess  has  preceded  most  of  those  which  have  been  studied. 
Many  micro-organisms  are  enclosed  within  the  cyst  walls,  and 
more  seem  for  a  time  to  be  gathered  in.  These  and  the  cellular 
elements,  which  also  wander  in  with  them,  disappear  by  solur 
tion.  Curiously  enough,  no  matter  how  many  micro-organisms 
may  appear  in  the  fluid  of  a  cyst,  none  will  grow.  Ever5d;hing 
entering  the  cyst,  enters  to  its  death,  whether  microbe,  leucocyte. 


PERIDENTAL    EPITHELIUM    AND    CYST    FORMATION.  397 

or  connective  tissue  cell.  The  contained  fluid  is  sterile,  yet  when 
spilled  out  into  the  tissues  it  may  be  toxic. 

From  the  clinical  observation  that  the  cyst  is  a  bag  contain- 
ing a  fluid  or  semifluid  material  within  a  membranous  capsule, 
and  that  severe  inflammation  has  sometimes  followed  the  pre- 
mature rupture  of  this  membrane,  surgeons  have  become  espe- 
cially careful  in  dissecting  them  out  complete.  If  a  portion  of 
a  cyst  wall  is  left  in  the  tissues,  it  will  usually  lead  to  the  redevel- 
opment of  the  cyst,  or  even  of  several  cysts,  more  or  less  closely 
joined  together. 

The  men  who  are  now  engaged  in  these  studies  are  giving 
the  formation  of  small  cysts  in  the  peridental  membrane,  espe- 
cially in  the  apical  portion,  a  good  deal  of  importance  in  connec- 
tion with  the  diseases  of  these  membranes.  Many  roots  of  teeth, 
with  chronic  alveolar  abscesses,  will,  when  extracted,  bring  away 
masses  of  soft  tissue  of  various  sizes,  attached  to  the  cementum, 
at  the  border  line  of  the  denuded  portion  of  the  root.  If  this 
tissue  is  prepared  for  microscopic  examination,  many  of  the 
smaller  specimens,  and  some  of  the  larger  ones,  will  be  found  to 
be  cysts  of  this  character. 

During  the  past  two  years  I  have  been  studying  these  cysts 
and  have  had  reproductions  made  of  a  number  of  photo- 
micrographs of  sections  prepared  in  my  laboratory,  which  illus- 
trate the  elements  composing  them.  Figures  467,  470,  471  and 
472  are  sections  through  the  entire  circumference  of  the  sur- 
rounding walls,  showing  variable  amounts  of  epithelial  elements 
lining  the  cavities,  these  being  enclosed  by  connective  tissue. 
Figures  474  and  475  are  higher  magnifications  of  sections  of 
these  cyst  walls,  and  Figure  476  is  a  still  higher  magnification 
of  the  cells  which  line  the  cvst. 


37 


398  SPECIAL,  DENTAL   PATHOLOGY. 


SYSTEMIC  EFFECTS  OF  CHRONIC 
INFECTIONS  OF  THE  MOUTH 

THE  loss  of  the  investing  tissues  and  final  loss  of  the  teeth 
constitute  only  the  local  side  of  the  picture  of  the  mouth 
infections  which  have  been  considered.  There  is  another  side 
that  is  even  more  important.  During  the  progress  of  the  dis- 
eases of  the  investing  tissues  of  the  teeth,  whether  caused  by- 
deposits  of  salivary  calculus,  or  in  the  form  of  pus  pockets  along- 
side the  roots,  or  chronic  alveolar  abscess,  there  is  a  continuous 
inflammation  of  low  degree  and  almost  continuous  suppuration, 
and  the  pus  formed  usually  is  itself  undergoing  putrefactive 
decomposition  through  the  growth  of  the  saprophytic  organisms. 
The  view  that  serious  systemic  infections  occur  as  a  result 
of  suppurations  in  the  mouth  has  been  powerfully  stimulated 
recently  by  a  few  notable  papers.  Articles  on  this  subject  have 
been  a  prominent  feature  of  both  the  medical  and  dental  litera- 
ture of  the  past  four  years.  In  reviewing  three  dental  journals 
and  one  medical  journal,  I  found  about  fifty  articles  published 
during  a  single  year. 

De.  Hunter's  paper  on  oral  sepsis. 

Dr.  William  Hunter,  a  surgeon  of  London,  published  an 
article  on  Oral  Sepsis*  in  1911,  in  which  he  lashed  the  dental 
profession  unsparingly  for  allowing  chronic  abscesses  and  other 
forms  of  chronic  suppurations  to  continue  in  the  mouth. 
Dr.  Hunter  called  attention  to  the  fact,  as  it  had  never  been 
done  before,  that  the  foci  in  the  mouth  are  in  the  same  causal 
relation  to  arthritis,  nephritis,  cholecystitis,  endocarditis,  etc., 
as  are  infected  tonsils,  or  chronic  suppurations  in  any  other 
location.  Dr.  Hunter  was  especially  severe  in  his  denunciation 
of  the  habit  of  placing  plates  over  infected  roots,  anchoring 
bridges  to  abscessed  teeth,  or  teeth  with  inflamed  and  suppu- 
rating gums,  or  placing  artificial  crowns  on  such  roots.    Any 

*  Eole  of  Sepsis  and  Antisepsis  in  Medicine,  Lancet,  Jan.  14,  1911. 


SYSTEMIC    EFFECTS   OF    MOUTH    INFECTIONS.  399 

constmction  that  gives  unclean  pieces  of  artificial  replacement 
came  in  for  his  condemnation. 

The  following  paragraphs  from  Dr.  Hunter's  article  give 
his  views  of  the  important  relation  of  oral  sepsis  to  the  general 
health : 

*^In  my  clinical  experience  septic  infection  is  without  excep- 
tion the  most  prevalent  infection  operating  in  medicine,  and  a 
most  important  and  prevalent  cause  and  complication  of  many 
medical  diseases.  Its  ill-etfects  are  widespread  and  extend  to 
all  systems  of  the  body.  The  relations  between  these  effects  and 
the  sepsis  that  causes  them  are  constantly  overlooked,  because 
the  existence  of  the  sepsis  is  itself  overlooked.  For  the  chief 
seat  of  that  sepsis  is  the  mouth;  and  the  sepsis  itself,  when 
noted,  is  erroneously  regarded  as  the  result  of  various  condi- 
tions of  ill-health  with  which  it  is  associated  —  not,  as  it  really 
is,  an  important  cause  or  complication. 

''The  causal  connexion  between  the  two  sets  of  processes  — 
the  sepsis  and  its  ill-effects  —  can  be  demonstrated  by  the  simple 
expedient  of  removing  the  sepsis,  and  noting  the  striking  effects 
which  the  removal  has  upon  the  existence,  character  and 
intensity  of  the  ill-effects.  The  ill-effects  referred  to  include  in 
individual  cases  every  one  of  the  diseases  described  in  the  fore- 
going section,  and  regarded  as  essentially  medical  in  their  char- 
acter—  viz.,  the  general  ill-health,  dirty,  sallow  complexions, 
the  indigestions,  the  gastric  and  intestinal  troubles,  the  ansemias 
which  resist  treatment;  tonsillitic,  pharyngeal  and  glandular 
troubles  of  children;  the  chronic  rheumatisms,  obscure  fevers 
and  blood  poisoning,  etc. 

"The  effects  are  not  the  same  in  all  cases,  any  more  than 
are  the  effects  of  septic  infection  in  surgery  or  those  of  tubercu- 
lous infection  in  medicine.  They  affect  sometimes  one  system 
and  sometimes  another,  in  different  degrees  according  to  the 
individual  susceptibility,  just  as  a  chronic  tuberculous  infection 
may  in  one  case  affect  the  glands  of  the  neck,  in  another  the 
joints,  in  another  the  bone,  in  another  the  lung,  in  another  the 
meninges,  in  another  the  peritoneum,  and  in  another  it  may 
affect  them  all 

"Sepsis  in  medicine  therefore  ranks,  in  my  experience,  as 
the  most  prevalent  and  potent  infective  disease  in  the  body. 
It  therefore  deserves  the  particular  attention  of  the  whole  pro- 


400  SPECIAL   DENTAL    PATHOLOGY. 

fession  as  mucli  as  it  has  hitherto  received  their  particular 
neglect.  It  requires  this  attention  at  the  hands  of  every  branch 
of  the  profession 

*'It  is  an  all-important  matter  of  sepsis  and  antisepsis  that 
concerns  every  branch  of  the  medical  profession,  and  concerns 
very  closely  the  public  health  of  the  community.  It  is  not  a 
simple  matter  of  'neglect  of  the  teeth'  by  the  patient,  as  is  so 
commonly  stated,  but  one  of  neglect  of  a  great  infection  by  the 
profession  —  a  great  infective  disease  for  which  the  patient  is 
not  primarily  responsible  any  more  than  he  is  responsible  for 
the  contraction  of  typhoid  fever  or  tuberculosis.  The  condition 
referred  to  is  that  to  which  I  have  given  the  name  of  'oral 
sepsis.' 

"The  title  '  oral  sepsis'  was  first  introduced  into  medical 
literature  in  a  paper  entitled,  'Oral  Sepsis  as  a  Cause  of  Dis- 
ease.' (British  Medical  Journal,  July,  1900.)  My  object  in 
seeking  for  a  special  name,  and  after  consideration  in  creating 
this  one,  was  to  emphasize  the  great  fact  that  it  is  not  the 
absence  of  teeth  but  the  presence  of  sepsis ;  that  it  is  not  dental 
defects,  but  septic  effects;  that  it  is  not  defective  mastication, 
but  the  effective  sepsis  associated  with  such  dental  defects,  or 
often  present  in  conditions  of  gingivitis  apart  from  such  defects, 
that  are  responsible  for  the  ill-health  associated  with  'bad' 
mouths. 

"The  second  object  was  to  emphasise  the  importance  of  the 
infection  caused  by  staphylococcal  and  streptococcal  organisms, 
as  distinguished  from  the  purely  saprophytic  infections  in  which 
the  mouth  abounds;  or  the  temporary  presence  of  specific 
organisms  —  e,  g.,  typhoid,  tubercle,  pneumonia,  etc. 

"The  subject  of  'oral  sepsis,'  as  I  designated  and  defined 
it  —  namely,  the  septic  lesions  of  streptococcal  and  staphylo- 
coccal infection  found  in  the  mouth  —  belongs  to  no  one  depart- 
ment of  medicine  or  surgery.  It  is  common  ground  on  which 
the  general  doctor,  physician,  or  surgeon;  the  throat,  nose,  ear 
and  eye  specialist;  specialists  in  children's  diseases,  in  stomach 
diseases,  in  blood  diseases,  in  'rheumatic'  diseases,  in  fevers,  in 
skin  diseases,  in  nervous  and  mental  diseases,  and,  lastly,  the 
dental  surgeon,  all  meet  on  terms  of  equal  responsibility.  In 
its  earliest  manifestations  no  special  knowledge  is  required  to 
deal  with  it;   a  sound  grasp  of  the  principles  underlying  anti- 


SYSTEMIC    EFFECTS   OF    MOUTH    INFECTIONS.  401 

sepsis  alone  is  required.     Unfortunately  for  the  patient  it  is 
precisely  this  grasp  which  I  grieve  to  say  is  wanting. 

"But,  it  is  urged,  the  condition  is  so  common  that  it  is 
impossible  either  to  prevent  it  or  to  deal  with  it  successfully; 
further,  the  ill-effects  are  few  and  rare  compared  with  the  wide 
prevalence  of  the  condition.  As  I  originally  showed  (1900), 
and  my  further  experience  of  the  last  ten  years,  supported  by 
that  of  many  others,  fully  demonstrates,  the  ill-effects  are  both 
common  and  grave.  That  they  are  not  more  common  is  due 
solely  to  the  great  resisting  power  possessed  by  the  mucosa  of 
the  mouth  and  gums. 

''This  matter  of  oral  sepsis  is,  therefore,  of  urgent  impor- 
tance in  relation  to  the  whole  multifarious  and  widespread  group 
of  affections  —  medical,  surgical  and  dental  —  caused  by  the 
actual  presence  of  toxic  action  of  pyogenic  organisms  (staphy- 
lococci and  streptococci)." 

De.  Billings'  investigations. 

In  reviewing  many  of  the  articles  upon  this  subject  which 
have  appeared  during  the  past  few  years  one  is  impressed  with 
the  fact  that  Dr.  Frank  Billings,  of  Chicago,  and  several  of  his 
associates,  particularly  Dr.  E.  C.  Rosenow,  have  made  the  most 
painstaking  and  thorough  studies  of  the  relationship  of  local 
foci  of  infection  to  general  systemic  conditions.  It  seems  that 
Dr.  Hunter  and  many  others  have  recognized  the  relationship 
principally  as  a  result  of  clinical  observation,  and  more  espe- 
cially by  noting  the  improvement  which  has  followed  the  extrac- 
tion of  the  teeth  in  hundreds  of  cases.  Dr.  Billings  and  his 
associates  have  found  the  organism  in  the  original  focus  in  the 
mouth  or  tonsil,  have  found  the  same  organism  in  the  inflamed 
joint,  or  other  secondary  lesion,  have  cultivated  this  organism, 
injected  it  into  animals,  produced  identical  lesions  in  the  animals 
and  finally  recovered  the  organism  from  the  affected  tissue  of 
the  animal.  This  chain  of  evidence  establishes  beyond  question 
the  relationship  of  the  local  focus  and  the  systemic  condition. 
These  studies  have  also  included  preparations  of  the  tissues 
involved  secondarily,  some  of  the  material,  as  in  cases  of  arthri- 
tis, being  taken  from  the  living  subjects,  other  material  being 
obtained  from  the  secondary  lesions  produced  in  animals. 

As  the  papers  by  Dr.  Billings  and  his  associates  practically 


402  SPECIAL   DENTAL   PATHOLOGY. 

cover  the  field,  I  give  a  list  of  their  writings  as  the  best  series  for 
reference.* 

An  interesting  symposium  appears  in  the  Journal  of  the 
American  Medical  Association  of  December  5,  1914  (Vol.  63, 
p.  2023)  to  which  Drs.  Gilmer,  Billings,  C.  H.  Mayo,  Rosenow 
and  Craig  are  contributors.  The  work  of  these  men,  and  many 
others,  has  served  to  establish  without  question  the  direct  rela- 
tionship of  the  mouth  focus  to  the  secondary  systemic  lesion. 

In  this  symposium  Dr.  Billings  says:  ''Systemic  disease 
due  to  a  focus  of  infection  anywhere,  is  probably  always  hema- 
togenous. The  study  of  the  infected  tissues  of  experimentally 
inoculated  animals  and  the  infected  muscles,  joint  tissues,  lymph- 
nodes  proximal  to  infected  joints,  nodes  on  tendons,  etc.,  of 
patients,  yield  specific  bacteria,  and  histologically  there  is  found 
embolism  of  the  small  and  terminal  blood  vessels.  Local  hemor- 
rhage and  endoarterial  proliferation  result  in  interstitial  over- 
growth, cartilaginous,  osseous,  vegetative  and  other  morbid 
anatomical  changes,  dependent  on  the  character  of  the  tissue 
infected. 

"Partial  or  complete  ischemia  of  the  tissues  due  to  the 
embolism  is  an  important  factor  in  the  production  of  the  morbid 
anatomic  changes.  Oxhausen  of  Berlin  has  produced,  in  ani- 
mals, aseptic  osteochondritis  resembling  arthritis  deformans,  by 
ligating  the  arteries  supplying  the  joint  tissues.  These  princi- 
ples are,  I  think,  susceptible  of  proof,  that  a  chronic  alveolar 

*  Chronic  Focal  Infections  and  Their  Etiologic  Relations  to  Arthritis  and  Nephri- 
tis. Frank  Billings,  Archives  of  Internal  Medicine,  Vol.  9,  1912,  p.  484.  Also,  Elinois 
Medical  Journal,  Vol.  21,  1912,  p.  261. 

Chronic  Oral  Infections.  Thomas  L.  Gilmer,  Illinois  Medical  Journal,  Vol.  21 
1912,  p.  275. 

Chronic  Focal  Infections  as  a  Causative  Factor  in  Chronic  Arthritis.  Frank  Bill 
ings.  Journal  of  the  American  Medical  Association,  Vol.  61,  1913,  p.  819. 

Clinical  Aspect  and  Medical  Management  of  Arthritis  Deformans.  Frank  Bill 
ings,  Illinois  Medical  Journal,  Vol.  25,  1914,  p.  11. 

Transmutations  within  the  Streptococcus-Pneumococeus  Group.  E.  C.  Rosenow 
The  Jour,  of  Infectious  Diseases,  Vol.  14,  Jan.,  1914,  p.  1. 

The  Etiology  of  Acute  Rheumatism,  Articular  and  Muscular.  E.  C.  Rosenow 
The  Jour,  of  Infectious  Diseases,  Vol.  14,  Jan.,  1914,  p.  61. 

Lesions  Produced  by  Various  Streptococci;  Endocarditis  and  Rheumatism.  E.  C 
Rosenow,  New  York  Medical  Journal,  February  7,  1914. 

Etiology  of  Arthritis  Defornians.  E.  C.  Rosenow.  Journal  of  the  American 
Medical  Association,  April  11,  1914,  p.  1146. 

The  Newer  Bacteriology  of  Various  Infections  as  Determined  by  Special  Methods. 
E.  C.  Rosenow,  Journal  of  the  American  Medical  Association,  Sept.  12,  1914,  p.  903. 

The  Medical  Management  of  Chronic  Arthritis.  Frank  Billings,  Illinois  Medical 
Journal,  September,  1914. 

Focal  Infection,  Its  Broader  Application  in  the  Etiology  of  General  Disease. 
Frank  Billings,  Journal  of  the  American  Medical  Association,  Vol.  63,  1914,  p.  2024. 

Bacteriology  of  Cholecystitis  and  Its  Production  by  Injection  of  Streptococci. 
E.  C.  Rosenow,  Journal  of  the  American  Medical  Association,  Nov.  21,  1914,  p.  1835. 


SYSTEMIC    EFFECTS   OF    MOUTH    INFECTIONS.  403 

infection,  and  chronic  foci  in  other  regions  also,  may  cause 
systemic  disease  by  hematogenous  bacterial  emboli,  which  infect 
and  at  the  same  time  deprive  the  tissues  of  nourishment.  Local 
infection  of  muscles,  joint  tissues,  etc.,  and  lessened  blood-supply 
result  in  the  peculiar  morbid  anatomy  of  the  respective  tissues. 

''To  investigate  and  manage  these  patients  requires  team 
work  of  the  clinical  and  laboratory  workers.  The  clinician  must 
carefully  examine  the  patient,  exhausting  every  detail  in  the 
personal  history.  The  skill  of  the  dentist,  the  nose  and  throat 
specialist,  the  gjniecologist,  the  genito-urinary  expert  and  others 
may  be  necessary  to  locate  the  foci  of  infection.  The  focus  must 
be  destroyed.  Tissues  and  exudates  of  foci  should  be  carefully 
examined  and  bacterial  cultures  made.  Vaccines  of  the  domi- 
nant bacteria  may  be  made  for  subsequent  use.  .  .  . 

''Autogenous  vaccines  may  be  used  in  the  attempt  to 
improve  the  defenses  of  the  body.  In  chronic  arthritis,  with  the 
circulation  of  the  infected  tissues  obstructed  embolically,  anti- 
bodies in  the  blood  stream,  even  if  augmented  by  vaccines,  would 
have  but  little  effect  locally.  .  .  .  When  the  local  circulation  has 
been  so  improved  that  the  tissues  are  flooded  with  blood,  vaccines 
will  be  of  undoubted  value. ' ' 

De.    RoSENOW's   STUDIES. 

Dr.  Rosenow  calls  particular  attention  to  the  differences 
found  and  the  changes  which  occur  in  the  organisms  in  the  foci. 
He  says: 

"One  striking  thing  in  connection  with  some  of  the  more 
chronic  infections  is  that  the  character  of  the  micro-organisms 
found  in  the  lesion  may  be  quite  different  from  the  character  of 
the  micro-organisms  in  the  focus  of  infection  at  the  same  time. 
This,  however,  does  not  minimize  the  importance  of  the  focus  of 
infection  in  any  way.  The  organisms  found  in  the  tissues  may 
have  undergone  change.  This  fact  should  be  borne  in  mind 
whenever  autogenous  vaccines  are  to  be  used.  The  poor  results 
in  some  cases  of  arthritis,  for  example,  following  the  use  of 
autogenous  vaccines  prepared  from  the  tonsils  or  other  pre- 
sumable focus,  may  be  due  to  the  fact  that  the  organisms  present 
in  the  focus  at  the  particular  time  when  the  cultures  wore  made 
were  not  like  those  actually  infecting  the  tissues.  And  if  so, 
the  vaccine  would  fail  to  contain  the  proper  antigen 

"My  study  of  the  effect  of  varying  degrees  of  oxygen  ten- 
sion on  the  members  of  the  streptococcus  group,  together  with 
other  facts,  makes  it  likely  that  it  is  in  the  focus  of  infection  that 


404  SPECIAL.   DENTAL   PATHOLOGY. 

changes  iu  virulence  occur  and  the  different  affinities  for  various 
structures  are  acquired.  In  other  words,  the  focus  of  infection 
is  to  he  looked  on  not  only  as  the  place  of  entrance  of  the 
bacteria,  but  also  the  place  where  the  organisms  acquire  the 
peculiar  property  necessary  to  infect.  In  the  light  of  our  pres- 
ent knowledge  the  argument  that  infections  in  the  mouth  are  so 
common  in  individuals  in  apparent  health,  does  not  minimize 
their  importance.  These  or  other  foci  are  so  common  in 
patients  suffering  from  arthritis,  neuritis,  appendicitis,  ulcer  of 
the  stomach,  cholecystitis,  goiter,  etc.,  and  so  rare  in  individuals 
who  have  had  superb  health  for  years,  that  their  direct  etiologic 
role  can  scarcely  be  questioned." 

One  of  the  most  interesting  features  of  Dr.  Rosenow's  work 
was  presented  in  a  paper  entitled,  Bacteriology  of  Vascular 
Infection,  read  before  a  joint  meeting  of  the  Chicago  Surgical 
and  Pathological  Societies,  on  January  8,  1915.  Dr.  Rosenow 
reported  the  results  of  experiments  on  animals  with  pure  cul- 
tures of  streptococci.  These  were  from  cases  of  appendicitis, 
ulcers  of  the  stomach,  cholecystitis  and  arthritis  in  humans,  and 
the  injections  were  made  into  animals,  mostly  rabbits  and  dogs, 
usually  into  the  ear  or  leg  veins.  Subsequent  examination  of 
the  animals  revealed  the  fact  that  the  streptococci  in  a  large 
majority  of  cases  produced  lesions  in  the  animals  in  the  same 
locations  and  of  similar  character  to  those  in  the  person  from 
whom  the  culture  was  obtained,  for  example: 

Fifty-nine  animals  were  injected  with  fresh  cultures  from 
cases  of  appendicitis,  and  of  these  41  were  found  to  have  devel- 
oped inflammations  of  the  appendix ;  while  5  showed  either  ulcer 
or  hemorrhage  of  the  stomach,  1  an  inflammation  of  the  gall 
bladder,  17  of  joints,  13  of  the  endocardium,  5  of  the  myocar- 
dium, 7  of  muscles,  4  of  kidneys,  and  4  inflammations  elsewhere 
in  the  intestines. 

Seventy-nine  animals  were  injected  with  fresh  cultures  from 
ulcers  of  the  stomach,  and  of  these  47  were  found  to  have  devel- 
oped hemorrhage  of  the  stomach  or  duodenum,  and  50  developed 
ulcers,  while  only  2  showed  inflammation  of  the  appendix,  20 
of  the  gall  bladder,  3  of  the  pancreas,  10  of  joints,  9  of  endo- 
cardium, 5  of  myocardium,  5  of  kidneys,  and  7  lesions  in  the 
intestines. 

Twenty-seven  animals  were  injected  with  fresh  cultures 
from  cases  of  cholecystitis,  and  of  these  22  developed  inflamma- 
tions of  the  gall  bladder,  while  none  showed  inflammation  of  the 
appendix,  9  showed  hemorrhage  or  ulcer  of  the  stomach,  1  of 


SYSTEMIC    EFFECTS   OF    MOUTH    INFECTIONS.  405 

pancreas,  5  of  joints,  4  of  endocardinm,  1  of  myocardium,  3  of 
muscles,  2  of  kidneys,  and  2  inflammations  in  the  intestines. 

Seventy-one  animals  were  injected  with  fresh  cultures  from 
cases  of  arthritis,  and  of  these  47  developed  joint  inflammations, 
3.3  of  the  endocardium,  31  of  the  myocardium,  19  of  the  pericar- 
dium 19  of  muscles,  and  28  of  kidneys,  while  only  6  devel- 
oped'inflammation  of  the  appendLx,  16  hemorrhage  and  13  ulcers 
of  the  stomach,  2  inflammations  of  the  gall  bladder,  and  2  ot  the 
pancreas. 

Similar  experiments  were  conducted  by  injecting  strep- 
tococci which  had  been  cultivated  through  several  generations. 
These  caused  inflammations  markedly  less  in  number,  and 
showed  much  less  tendency  to  establish  themselves  m  the  same 
locations  in  the  animals  as  in  the  individuals  from  whom  the 
cultures  were  obtained. 

These  experiments  seem  to  have  established  beyond  question 
the  importance  of  the  blood  stream  as  a  carrier  of  infection,  and 
also  the  very  peculiar  and  as  yet  unexplained  tendency  for  the 
organisms  to  cause  the  same  diseases  in  the  animals  as  m  the 
individuals  from  whom  the  cultures  were  obtained. 

The  organisms  in  the  primary  focus. 

It  is  an  interesting  fact  that,  in  all  of  the  cases  of  this  group, 
the  primary  foci  is  a  suppurative  lesion,  while  the  secondary 
systemic  condition  usually  is  not.  It  must  be  that  the  pus- 
producing  organism  in  the  primary  focus  does  not  produce  the 
secondary  lesion,  or  else  the  morpholog>^  of  the  organism  is 
materially  changed.  If  the  pus-producing  organism  of  the  origi- 
nal focus  is  not  changed,  then  the  secondary  manifestations  are 
caused  by  a  non-pyogenic  organism  which  accompanies  or  fol- 
lows the  pus  producer  into  the  original  focus. 

The  systemic  lesion  is  generally  the  result  of  a  hematoge- 
nous infection,  and  although  the  infecting  organism  may  not 
be  responsible  for  the  primary  focus,  it  may  nevertheless  gain 
access  to  the  blood  stream  from  such  focus.  The  finding  ot  he 
same  organism  in  both  lesions  is  not  absolute  proof  that  the 
primary  focus  is  the  real  cause,  or  the  only  cause,  as  there  may 
be  other  foci  through  which  the  same  organism  may  enter  the 
circulation. 

Pus  formation,  in  and  of  itself,  is  confined  almost  exclusively 
to  the  liquefaction  of  inflammatory  exudates,  often  releasing  and 


406  SPECIAL   DENTAL   PATHOLOGY. 

destroying  considerable  areas  of  forming  granulation  tissue. 
The  epiphenomenon  injected  here  is  found  to  be  saprophytic 
organisms  which  decompose  the  pus,  forming  its  very  irritant 
qualities. 

The  point  in  this  particular  consideration  is  this.  We  have 
suppurations  occurring  in  the  mouth  that  are  simple  in  their 
form  —  that  is  to  say,  the  micro-organisms  producing  pus  are 
the  only  ones  active  in  the  disease.  They  are  indeed  the  disease- 
producing  power  in  these  cases,  and  if  they  act  alone  they  may 
produce  no  very  great  systemic  disturbance.  But  in  many  cases 
an  epiphenomenon  is  ingrafted  upon  this  disease  by  the  intro- 
duction of  saprophytic  micro-organisms  which  decompose  the 
pus  formed ;  or  other  organisms  may  enter  the  focus  and  these 
may  become  the  most  important  element  in  the  establishment  of 
the  secondary  lesions. 

This  interference  with  the  ordinary  run  of  pus  formation  is 
especially  common  in  the  infections  of  the  mouth,  for  the  reason 
that  the  mouth  secretions  are  constantly  loaded  with  a  large 
flora.  These  will  grow  for  a  time  in  the  mouth  secretions  and 
may  be  included  with  those  which  cause  the  suppurations.  These 
may  be  pathogenic  varieties  which  will  increase  the  difficulties 
by  engrafting  their  effects  upon  those  of  ordinary  pus-producing 
forms. 

The  saprophytic  organisms  never  grow  in  living  tissues, 
but  only  in  the  fluids  which  have  been  separated  from  living  tis- 
sues. They  decompose  these  fluids,  and  in  the  decomposition, 
products  are  formed  which  are  poisonous  and  are  absorbed  into 
the  general  system.  This  has  been  called  blood  poisoning. 
Many  examples  of  this  occur  in  the  fleshy  foods  eaten  which 
have  begun  decomposition  that  is  not  noticed.  The  ingestion 
of  such  food  will  carry  with  it  this  poison  and  make  the  patient 
very  sick  for  a  time.  In  general  theory  its  action  is  like  a  dose 
of  poisonous  medicine.  It  comes  quickly  and  sharply,  and  if 
the  patient  survives  its  action,  it  gradually  passes  away  —  that 
is,  when  the  poison  is  once  expended,  it  is  done.  This  is  gener- 
ally spoken  of  as  ptomain  poisoning.  But  such  an  organism 
growing  in  pus  that  is  being  produced  continuously,  will  grow 
for  a  time,  producing  a  systemic  condition  by  a  slow  absorption 
of  these  products,  which  is  often  very  serious.  Therefore  treat- 
ment may  be  for  the  prevention  of  these  saprophytic  growths, 
or  their  eradication  when  present,  as  well  as  for  the  cure  of  the 
pus  formation  itself. 


SYSTEMIC   EFFECTS   OF    MOUTH    INFECTIONS.  407 

Three  groups  of  chronic  foci  in  the  mouth. 

In  the  mouth  there  are  three  groups  of  chronic  foci:  (1) 
Deposits  of  salivary  calculus,  with  which  may  be  included  cer- 
tain fillings,  crowns,  bridges,  etc.,  which  impinge  on  the  gmgivse 
and  keep  them  in  a  state  of  constant  low-grade  mflammation; 
(2)  pus  pockets  alongside  the  roots ;  (3)  chronic  alveolar  abscess. 
Of  the  three  groups  of  foci,  it  is  important  to  note  that  the 
conditions  presenting  in  the  first  group  are  such  that  the  focus 
may  be  easily  eradicated  by  the  treatment  which  has  already 
been  mentioned.  The  removal  of  the  deposits  pennits  the 
inflamed  tissue  to  recover  almost  immediately.  It  is  then  a  ques- 
tion of  preventing  new  deposits.  The  removal  or  modification 
of  fillings,  crowns,  etc.,  avoids  future  irritation  and  eliminates 
the  focus,  in  cases  in  which  pockets  have  not  already  been 
formed  alongside  the  roots. 

The  pus  pocket  is  best  adapted  for  catching  all  of  the 
numerous  organisms  which  may  be  floating  in  the  mouth,  and 
transmitting  them  to  the  blood  stream.  The  granulation  tissue 
overlying  the  roots  is  very  soft,  and  new  blood  vessels  are  being 
constantly  formed  and  destroyed,  presenting  extraordinary 
opportunities  for  the  hematogenous  organisms  withm  the  pocket 
to  enter  the  circulation. 

The  peridental  membrane  is  detached  from  the  cementum  by 
suppuration,  and  this  becomes  the  important  factor  in  maintain- 
ing the  chronicity.  As  a  part  of  this  process  the  cementoblasts 
which  overlie  the  surface  of  the  cementum  within  the  peridental 
membrane  are  also  destroyed.  These  are  the  only  cells  which 
could  cause  reattachment  of  that  tissue.  Soon  after  detachment, 
the  fibers  of  the  peridental  membrane,  which  formerly  passed 
from  the  cementum  of  the  detached  area  to  the  bone,  disappear, 
and  a  little  later  the  bone  to  which  they  were  attached  is 
absorbed.  Thus,  in  addition  to  the  fact  that  the  denuded  cemen- 
tum is  dead,  all  of  the  specialized  elements  necessary  to  the 
connection  of  root  with  bone  are  lost,  and  a  reattachment  of  tins 
tissue  to  the  cementum  of  the  root  can  not  take  place.  There- 
fore pockets  remain  about  such  teeth  and  are  subject  to  frequent 
reinfection. 

In  the  case  of  the  chronic  alveolar  abscess,  the  chronicity  may 
be  maintained  by  the  dead  pulp,  if  it  remains  in  the  tooth,  or  by 
the  denuded  cementum  about  the  end  of  tlie  root.  In  cases  m 
which  the  peridental  membrane  about  the  apex  is  not  destroyed, 
the  treatment  of  the  root  canal  should  eliminate  the  focus.     If 


408  SPECIAL   DENTAL   PATHOLOGY. 

the  cementum  has  been  denuded,  the  condition  is  practically  the 
same  as  the  pus  pocket  which  is  open  at  the  gingival  line,  so  far 
as  the  continued  chronicity  is  concerned,  as  there  is  no  possi- 
bility of  a  reattachment.  The  chronic  abscess  has  not  the  same 
exposure  to  the  fluids  of  the  mouth  as  has  the  pus  pocket,  and 
does  not  present  the  same  opportunity  for  direct  reinfection. 

We  should  not,  therefore,  expect  vaccines  to  have  more  than 
temporary  effect  on  the  local  focus,  because  there  does  not 
remain  the  physiologic  possibility  of  repair.  The  dental  treat- 
ment indicated  is  the  elimination  of  the  focus  in  the  case  of  the 
alveolar  abscess,  which  has  destroyed  the  attachment  of  the 
membrane,  by  resecting  the  denuded  root  end  or  the  extraction 
of  the  tooth.  If  it  is  a  pocket  alongside  the  root,  exposed  to  the 
fluids  of  the  mouth,  the  tooth  must  be  extracted,  or  palliative 
treatment  employed  which  will  be  effective  against  reinfections. 

The  pus  and  products  of  putrefaction  and  various  organisms 
which  may  be  present,  especially  the  hematogenous  varieties,  are 
entering  the  blood  through  the  thin-walled  vessels  in  the  loosened 
tissues,  which  are  in  a  constant  state  of  chronic  inflammation  of 
low  degree.  The  lymphatic  system  is  also  taking  up  its  quota 
of  these  poisonous  materials,  and  the  small  lymphatic  glands  at 
the  angles  of  the  neck  are  often  in  a  chronic  state  of  mild,  or 
more  considerable,  enlargement.  Under  these  conditions  the 
general  health  of  the  robust  patient  is  put  to  a  test  of  its 
strength  to  maintain  itself  without  notable  impairment.  Many 
l^ersons  of  the  weaker  sort  become  subjects  of  a  low  degree  of 
septicemia,  which  spreads  its  peculiar  pallor  over  their  counte- 
nances, saddens  them,  and  they  lead  lives  constantly  bordering 
upon  actual  illness.  And  not  a  few  of  these  succumb  to  some 
intercurrent  disease,  which,  but  for  the  condition  within  the 
mouth,  and  its  general  systemic  effect,  they  would  easily  have 
withstood. 

Defense  by  the  tissues. 

It  should  be  kept  in  mind  that  the  natural  resistance  of  the 
tissues  is  inclined  to  prevent  or  retard  the  occurrence  of  sys- 
temic lesions  from  chronic  foci.  Probably  no  tissue  is  more 
vigorous  in  resisting  infection  than  the  mucous  membrane  of  the 
mouth.  The  presence  of  such  a  focus  does  not  indicate  that  the 
individual  is  suffering  from  systemic  eifects,  but  he  is  undoubt- 
edly in  constant  danger.  Certainly  many  people,  probably  the 
majority  of  those  who  have  such  foci  in  the  mouth,  will  continue 
in  excellent  health,  or  apparently  so,  for  years.     There  may 


SYSTEMIC    EFFECTS   OF    MOUTH    INFECTIONS.  409 

never  be  an  indication  that  their  health  and  vigor  liave  been 
impaired. 

On  the  other  hand,  it  should  be  remembered  that  the  definite 
secondary  lesions  resulting  from  these  foci  are  of  such  gradual 
development  that  they  are  generally  not  recognized  liy  the 
patient,  and  do  not  come  to  the  attention  of  the  physician  until 
they  have  made  such  progress  as  to  be  incurable,  or  at  least  very 
obstinate  in  their  amenability  to  treatment.  This  fact  demands 
the  eradication  of  the  foci  for  the  protection  of  the  health  of  all 
persons,  whether  apparently  suffering  or  not. 

The  dentist's  opportunity. 

The  opportunity  before  the  dental  profession  to  take  an 
important  part  in  the  preservation  of  the  general  health  is 
almost  without  parallel  in  medical  advancement.  There  seems 
to  be  no  question  but  that  the  mouth  contains  more  such  foci 
than  all  other  regions  of  the  body  combined.  The  secondary 
effects  of  these  foci  present  great  difficulties  to  the  physician  in 
treatment.  The  foci  are  easily  recognizable  by  thorough  mouth 
examinations,  which  must  be  made  by  the  dentist.  The  means  of 
protecting  the  general  health  in  their  treatment  are  simple. 
Success  depends  upon  a  full  understanding  of  the  situation  by 
both  physician  and  dentist,  together  with  the  education  of  our 
people  to  the  danger  from  the  primary  focus,  the  insidious 
progress  of  the  secondarj^  effect,  and  its  intractableness  to 
treatment. 

The  dentist  should  apply  treatment  on  the  basis  of  a  careful 
diagnosis  and  his  knowledge  of  the  danger  to  the  person  who 
apparently  is  in  perfect  health.  This  is  preventive  practice  in 
the  highest  degree.  Eradication  of  mouth  foci  should  not  be 
delayed  until  secondary  effects  have  become  manifest.  Every 
dentist,  who  has  a  full  appreciation  of  the  situation,  will  realize 
that,  in  the  management  of  cases,  he  is  doing  his  highest  duty 
to  humanity  in  the  preservation  of  health  by  keeping  the  mouths 
under  his  care  free  from  these  centers  of  distribution  of 
infection. 

Summary. 

In  the  light  of  our  present  knowledge,  we  are  justified  in 
making  the  following  summary  of  the  relation  of  mouth  foci  to 
general  systemic  conditions: 

1.  The  mouth  contains  a  large  variety  of  mioro-organisms, 
which  may  be  divided  iuto  two  groups;   those  which  are  normal 


410  SPECIAL   DENTAL   PATHOLOGY. 

or   constantly   present,    and   those    occasionally   or   frequently 
found. 

2.  Conditions  in  the  mouth  are  such  that  slight  inflamma- 
tions of  the  gingivaB  are  of  frequent  occurrence,  being  present 
in  about  ninety-five  per  cent  of  mouths  of  adults. 

3.  These  slight  inflammations,  if  untreated,  may  gradually 
progress  to  chronic  suppurations.  The  suppurations  are  caused 
by  organisms  normal  to  the  mouth. 

4.  All  organisms  in  the  mouth,  whether  normal  or  acci- 
dentals, have  access  to  the  blood  stream  through  the  soft 
granulations. 

5.  The  normal  resistance  tends  to  prevent  systemic  effects 
and  is  apparently  successful  in  the  large  majority  of  cases. 

6.  The  transmission  of  infection  from  the  primary  focus  is 
principally  hematogenous. 

7.  The  primary  focus  is  characterized  by  suppuration, 
while  the  secondary  lesion  is  non- suppurative.  Therefore  the 
secondary  lesion  is  not  caused  by  the  principal  organism  of  the 
primary  focus,  but  by  other  organisms  which  enter  the  primary 
focus  with  or  after  the  pus  producer,  and  thus  gain  access  to  the 
circulation ;  or  else  the  morphology  of  the  pyogenic  organism  is 
changed  if  it  produces  the  secondary  lesion. 

8.  The  organisms  entering  the  circulation  through  such 
foci  appear  to  have  an  as  yet  unexplained  tendency  to  locate  in 
particular  tissues. 

9.  The  secondary  effects  include  a  very  wide  range  of  con- 
ditions. Chronic  arthritis,  endocarditis,  nephritis,  cholecystitis, 
ulcers  of  the  stomach,  and  appendicitis  are  the  most  frequent 
definite  lesions.  General  impairment  of  health  and  vigor,  with 
or  without  recognizable  lesions,  is  common. 

10.  The  secondary  effects  are  usually  insidious  in  their 
onset  and  progress,  and,  when  cases  present  to  the  physicians  for 
treatment,  are  difficult  of  management. 

11.  It  is  imperative  that  the  primary  foci  be  eliminated, 
regardless  of  the  apparent  systemic  effect  or  lack  of  systemic 
effect. 

12.  For  the  reason  that  the  mouth  contains  the  primary 
foci  in  the  large  majority  of  cases,  a  great  opportunity  is  open 
to  the  dental  profession  to  prevent  grave  systemic  disease. 


OEAL    PEOPHYIiAXIS.  411 


ORAL  PROPHYLAXIS 

PROPHYLAXIS  may  be  defined  as  preventive  treatment  for 
disease,  especially  for  a  particular  form  of  disease  in  an 
individual.  Oral  Prophylaxis  should  therefore  include  the 
treatment  employed,  mostly  by  the  dentist,  to  prevent  particular 
diseases  in  the  mouths  of  individual  patients.  There  should  be 
recognized  a  danger  of,  or  a  tendency  toward,  a  certain  disease 
in  the  mouth  of  the  individual,  and  the  measures  taken  to  pre- 
vent it  constitute  the  practice  of  oral  prophylaxis. 

GENERALi   PROPHYLAXIS. 

The  methods  employed  in  the  prevention  of  disease  will 
differ  with  almost  every  disease  with  which  we  deal,  and  must 
be  based  upon  an  accurate  knowledge  of  the  causation  of  each. 
For  instance,  when  the  United  States  undertook  the  task  of 
building  the  great  Isthmian  canal,  the  locality  was  found  to  be 
infested  with  yellow  fever,  and  a  much  dreaded  miasma,  so 
called.  The  French  had  made  an  attempt  to  build  the  canal  and 
failed,  largely  because  so  many  of  their  men  were  rendered  ineffi- 
cient or  died  from  these  diseases.  Our  scientists  had  learned, 
while  dealing  with  the  Cuban  proposition  in  the  latter  part  of 
the  nineties,  that  yellow  fever  was  communicated  to  men  by  a 
certain  species  of  mosquitoes  (stegomyia)  and  also  that  the 
so-called  miasma  was  communicated  to  men  by  another  variety 
of  the  mosquito  (anophiles). 

The  first  thing  our  Government  did  in  Panama  was  to  place 
an  army  of  men  immune  to  yellow  fever  (by  reason  of  having 
had  the  disease  and  recovered)  into  the  zone  to  destroy  the 
breeding  places  of  these  mosquitoes  everywhere  within  a  mos- 
quito's flight  of  the  zone  of  canal  building.  The  prevention  of 
the  diseases  has  been  practically  complete. 

In  this  way  a  veritable  pesthole  was  quickly  converted  into 
a  healthful  place.  Really  very  little  sickness  of  any  kind  has 
occurred  among  the  great  army  of  men  at  work  there.  This  is 
prophylaxis  on  a  large  scale.  However,  it  is  not  a  form  of 
prophylaxis  that  would  prevent  the  diseases  that  we  are  con- 
tending with  in  dentistry.    Again,  a  serum  has  been  discovered, 


412  SPECIAL   DENTAL   PATHOLOGY. 

which  quickly  renders  a  child  immune  (temporarily)  to  diph- 
theria. Another  immunizes  against  tetanus  successfully,  a 
dreadful  form  of  disease  from  which  few  persons,  if  any,  recov- 
ered before  the  use  of  the  serum. 

Personally,  I  have  had  no  experiences  with  yellow  fever, 
but  with  diphtheria  I  had  a  fairly  wide  experience  before  the 
discovery  of  the  diphtheria  serum,  and  it  was  sufficiently  terrible 
to  cause  me  to  appreciate  the  value  of  the  serum  treatment. 
I  also  saw  much  of  tetanus  before  the  serum  treatment  came  to 
our  aid.  It  was  certain  death  to  the  person  attacked.  One 
among  the  last  cases  with  which  I  had  to  do  makes  a  little  stor^^ 
which  I  will  relate.  One  morning  a  young  physician  came  to 
me  and  asked  me  to  go  with  him  to  see  a  patient,  a  boy  about 
twelve  years  old,  whom  he  had  been  called  to  see  the  day  before. 
The  boy  had  cut  his  great  toe  with  an  ax.  The  physician  had 
stitched  up  the  cut,  which  seemed  unimportant.  The  next  morn- 
ing he  happened  to  be  passing  the  house  and  stepped  in  to  see 
the  boy.  The  little  fellow  seemed  well  enough,  was  going  about 
the  house,  but  was  holding  the  sore  toe  up  rather  high  from  the 
floor.  The  doctor  asked  him  to  put  it  down  on  the  floor.  The 
boy  said  he  couldn't.  The  doctor  put  it  down  with  his  hand, 
but  it  would  not  stay.  He  recognized  at  once  that  the  case  was 
unusual,  and  suspected  tetanus,  although  he  had  never  seen  a 
case.  He  told  the  family  that  he  would  come  back  after  a  while, 
and  came  directly  to  see  me,  knowing  that  I  had  had  experience 
with  tetanus. 

I  saw  the  boy  with  him  and  found  it  undoubtedly  a  case  of 
tetanus,  just  in  the  initial  stage.  All  of  such  cases  I  had  seen 
had  ended  in  death  after  a  struggle  of  the  most  desperate  char- 
acter. It  was  an  ugly  situation.  Here  was  a  boy  attacked  with 
a  disease  that  would  certainly  cause  his  death  unless  something 
very  unusual  could  be  done.  I  had  studied  the  disease  carefully, 
had  cultivated  the  micro-organism  that  caused  it,  and  at  the  time 
felt  that  I  knew  all  there  was  to  be  known  about  it,  including  the 
impotency  of  drugs  to  check  it.  The  boy  would  die  except  one 
desperate  chance  might  save  him.  The  infection  had  not  yet 
spread  far.  I  proposed  to  the  physician  that  he  amputate  the 
leg  at  the  middle  of  the  thigh  within  an  hour.  To  this  he 
assented.  We  called  the  parents  and  explained  the  whole  matter 
as  carefully  as  seemed  possible.  But  say  what  we  could,  the 
father  was  simply  furious.  The  idea  that  his  boy,  who  seemed 
so  well  in  every  way  and  was  at  that  moment  placing  cheerfully 
with  some  traps  he  had  been  constnicting,  watching  the  working 


ORAL   PROPHYLAXIS.  41o 

of  the  triggers,  should  be  required  to  submit  to  such  an  opera- 
tion, could  not  be  entertained  by  him.  Other  counsel  was  sent 
for,  and  after  careful  examination,  gave  the  same  advice.  It 
was  no  use.  The  parents  would  not  have  it.  The  next  day  the 
boy  was  not  playing  with  his  traps.  The  possibility  of  helping 
him  by  an  amputation  had  passed.     He  died  after  eight  days. 

With  diphtheria,  which  endangers  whole  neighl)orhoods  of 
children,  it  is  different.  This  disease  is  cut  short  in  the  child 
who  is  just  becoming  sick  with  it,  and  is  prevented  by  immuniz- 
ing other  children  who  are  as  yet  well.  This  is  prophylaxis  in 
a  true  sense. 

At  one  time  I  was  occupied  in  the  management  of  epidemics 
of  typhoid  fever.  In  this  it  was  different  again,  and  it  depended 
upon  a  much  wider  knowledge  of  the  source  of  infection.  In 
cases  where  the  spread  of  the  disease  depended  upon  sick  per- 
sons coming  into  a  neighborhood  and  spreading  it,  all  tliat  was 
necessary  was  to  stop  the  transmission  from  one  to  another,  and 
to  see  that  the  minutiae  of  the  nursing  was  properly  done.  In 
this  the  greatest  difficulty  was  to  bring  people  to  an  understand- 
ing of  the  situation  and  secure  their  cooperation  by  compliance 
with  regulations  prescribed.  The  source  of  distribution  of  infec- 
tion —  in  the  ground,  in  the  water,  milk  or  other  food  —  had  to 
be  found  and  corrected. 

This  is  perhaps  enough  to  give  a  full  understanding  of  what 
prophylaxis,  or  the  prevention  of  a  specified  disease,  means. 
Prophylactic  treatment,  like  all  other  treatment,  should  be  based 
on  a  thorough  knowledge  of  the  etiology  and  pathology  of  the 
disease  under  consideration.  For  most  diseases,  the  treatment 
employed  has  naturally  become  more  effective  as  knowledge  of 
the  disease  became  more  complete ;  treatment  has  at  first  been 
for  the  alleviation  of  pain  or  some  distressing  symptom,  and 
later  has  gradually  been  directed  toward  the  underlying  cause 
or  condition.  When  the  complete  patholog}^  and  etiology  have 
been  worked  out,  it  has  often  been  possible  to  apply  preventive 
treatment,  as  is  now  done  in  diphtheria,  tetanus,  typhoid,  etc. 
Preventive  treatment  can  usually  be  employed  when  the  otioU^gy 
is  fully  understood. 

ORAL    PROPHYLAXIS. 

Oral  Prophylaxis  includes  the  treatment  employed  to  pre- 
vent particular  diseases  in  the  mouths  of  individual  patients. 
In  its  broadest  sense,  this  includes  the  })rophylactic  ])haso  of 
practically  every  operation  wliich  the  dentist  perf»)rms.     In  a 

88 


414  SPECIAL   DENTAL.   PATHOLOGY. 

more  restricted  use  of  the  term,  it  has  been  commonly  applied  to 
a  more  or  less  systematic  plan  of  thoroughly  cleaning  and  polish- 
ing the  surfaces  of  the  teeth  at  stated  intervals. 

Such  a  large  proportion  of  our  people  are  subject  to  dental 
caries,  alveolar  abscess  and  diseases  of  the  peridental  mem- 
brane, and  the  consequences  of  chronic  foci  of  infection  in  the 
mouth  have  been  shown  to  be  so  far-reaching,  that  more  definite 
prophylactic  measures  should  be  very  generally  studied  and 
employed.  These  m-ay  well  be  divided,  for  each  condition,  into 
those  which  should  be  a  part  of  our  routine  dental  operations, 
and  those  technical  procedures  which  may  be  employed  inde- 
pendently. For  example,  in  the  placing  of  a  proximo-occlusal 
filling  in  a  molar  tooth,  the  operator  should  be  careful,  in  the 
preparation  of  the  cavity,  neither  to  expose  the  pulp  nor  to  cut 
so  closely  to  it  that  it  will  be  in  danger  of  death  from  thermal 
shock.  This  is  prophylaxis  against  the  death  of  the  pulp  and 
alveolar  abscess.  Also,  in  the  preparation  of  the  cavity,  the 
rules  of  extension  for  prevention  should  be  followed  in  obtaining 
the  outline  form,  thus  placing  the  margins  of  the  filling  in  self- 
cleansing  positions  and  thereby  preventing  a  recurrence  of 
decay.  This  is  prophylaxis  against  dental  caries.  Further,  in 
the  placing  of  the  filling,  the  proximal  surface  should  be  finished 
to  proper  form  with  a  good  contact,  so  that  the  interproximal 
gum  septum  will  be  protected  from  injury  by  food  lodgments. 
Thus  a  recurrence  of  decay  may  be  prevented  in  the  tooth  filled, 
a  beginning  of  decay  may  be  prevented  in  the  proximal  tooth, 
and  an.  inflammation  of  the  septal  tissue  may  be  avoided.  This 
is  prophylaxis  against  both  caries  and  peridental  disease. 

In  presenting  the  subject  of  oral  prophylaxis,  we  will  con- 
sider separately  those  procedures  which  may  be  employed 
against  dental  caries,  and  against  diseases  of  the  peridental 
membrane.  It  is  recognized  that  the  prevention  of  dental  caries, 
and  the  prompt  treatment  of  decays  which  have  occurred,  includ- 
ing the  precautious  for  preventing  inflammations  of  the  pulp, 
which  have  been  mentioned,  constitute  the  highest  degree  of 
prophylaxis  which  may  be  employed  against  diseases  of  the 
dental  pulp  and  their  sequelae  —  acute  and  chronic  alveolar 
abscess,  necrosis,  etc.  It  is  impracticable,  in  this  writing,  to 
mention  all  of  the  prophylactic  phases  of  our  routine  dental 
operations  in  relation  to  these  various  conditions.  Therefore, 
we  will  present  here,  for  each  condition,  only  those  technical 
procedures  which  may  be  employed  in  what  has  been  commonly 
termed  prophylactic  treatments.     A  grouping  of  these  will  show 


OKAL   PKOPHYLAXIS.  415 

that  we  are  justified  in  following  a  more  or  less  definite  tecbnic 
for  prophylactic  treatments,  with  certain  modifications  for  each 
individual.  Subsequently  a  systematic  plan  of  mouth  hygiene 
will  be  presented. 

The  oral,  prophylaxis  treatment,  so  called. 

For  a  number  of  years  past  there  has  been  much  talk  of 
prophylaxis  in  dentistry.  The  principal  credit  for  attracting 
the  attention  of  the  profession  to  this  subject  is  due  Dr.  D.  D. 
Smith,  of  Philadelphia.  The  plan  suggested  for  preventing  the 
occurrence  of  disease  in  the  mouth,  including  caries  and  diseases 
of  the  gingivae,  is  that  the  patient  visit  the  dentist  at  stated  times, 
varying  from  once  every  week  or  ten  days  to  once  every  month  or 
so,  in  order  that  every  surface  of  every  tooth  may  be  scoured  with 
pumice  on  the  end  of  a  stick  of  orangewood  or  similar  substance. 
For  proximal  surfaces,  strips  of  some  delicate  fabric  are  used. 

This  idea  of  prophylaxis  had  a  considerable  following  for  a 
number  of  years  and  is  still  practiced  by  some  very  good  men. 
A  considerable  part  of  this  service  came  to  be  turned  over  to 
young  women  assistants,  who  were  especially  trained  for  it. 
What  was  done  by  the  patient  in  the  cleaning  processes  in  the 
interim  between  visits  to  the  dentist,  has  never  been  so  clearly 
shown,  but  it  is  safe  to  say  that  the  patient  was  trained  in  the 
care  of  the  mouth  between  visits  to  the  dentist. 

It  has  been  my  judgment  that  this  plan  of  prophylaxis  was 
much  too  heavy  in  its  continuous  operation  to  be  successful.  Also, 
that  if  it  were  kept  up,  as  represented,  much  harm  would  be  done 
to  the  margins  of  the  gingivae  by  the  scrubbing  with  pumice  on  a 
stick,  and  probably  greater  harm  still  to  the  attachment  of  the 
soft  tissue  at  the  gingival  line  by  the  use  of  tapes  so  frequently 
as  once  per  month  for  a  number  of  years  together.  Recently  we 
are  hearing  much  less  of  this  plan  of  prophylaxis  in  dentistry. 
I  strongly  suspect  that  one  of  the  difficulties  found  has  been  to 
keep  patients  sufficiently  responsive  to  their  engagements  for 
these  cleaning  processes.  However,  the  plan  has  in  it  the  phase 
of  continuity  which  has  a  high  value. 

In  the  management  of  the  diseases  with  which  we  are  con- 
tending, the  practical  procedures  in  oral  prophylaxis  should  take 
their  place  in  the  routine  care  of  the  mouth  of  each  individual, 
having  their  proper  relation  to  other  operations,  and  both  should 
be  supplemented  by  proper  training  of  patients  in  a  systematic 
plan  of  mouth  hygiene.  No  one  of  these  elements  in  the  care  of 
the  mouth  can  be  set  apart  and  be  successfully  employed  alone  in 


416  SPECIAL   DENTAL    PATHOLOGY. 

many  cases.  For  most  people,  there  is  such  an  interdependence 
of  what  may  be  termed  the  regular  dental  operations,  oral  pro- 
phylaxis and  mouth  hygiene,  that  all  must  be  employed  if  the 
mouth  is  to  be  maintained  in  the  best  state  of  health. . 

The  teclmic  of  the  prophylactic  treatment  is  simple.  It  con- 
sists of  the  very  thorough  scouring  and  cleaning  of  the  surface 
of  the  enamel,  and  of  denuded  root  surfaces.  It  should  not  as  a 
rule  go  further  than  this.  A  limited  number  of  very  shallow 
penetrations  of  the  enamel  by  caries,  particularly  in  gingival 
third  positions  on  buccal  and  labial  surfaces,  should  be  treated  by 
grinding  away  some  of  this  enamel  to  make  the  surface  smooth. 
The  very  radical  practice  recommended  by  a  few,  of  grinding 
awa}^  the  outer  surface  of  undecayed  enamel,  is  to  be  condemned. 

Application  to  dental  caries.  I  have  already  called  atten- 
tion to  the  fact  that  in  its  broader  meaning,  we  are,  or  should  be. 
applying  oral  prophylaxis  against  dental  caries  in  almost  every 
operation  which  we  perform.  With  each  operation  we  will,  to  a 
greater  or  less  measure,  help  to  prevent  the  progress  of  caries  in 
the  particular  mouth,  if  we  are  giving  our  patients  the  best 
possible  service. 

But  we  are  to  consider  what  may  be  accomplished  by  what  we 
have  designated  as  the  oral  prophylaxis  treatment  to  prevent  the 
inception,  or  progress,  of  dental  caries.  In  the  application  of 
this  treatment,  as  of  any  other,  we  must  have  the  clearest  possible 
understanding  of  the  pathological  problems  involved. 

So  far  as  the  treatment  of  caries  is  concerned,  this  service 
has  been  undertaken  by  those  who  have  specialized  in  it,  under 
the  slogan  that  ''clean  teeth  do  not  decay."  This  means  that  by 
such  treatment  the  teeth  must  be  kept  clean,  and  the  question 
naturally  arises,  how  frequently  must  such  a  treatment  be  given 
in  order  to  keep  the  teeth  sufficiently  clean.  The  answer  must  be 
that  it  will  depend  on  the  susceptibility  or  immunity  of  the  indi- 
vidual. Some  persons  are  so  absolutely  immune  to  caries  that 
such  treatment  would  never  be  necessary  against  caries,  while 
others  are  so  susceptible  that  I  can  hardly  conceive  of  cleanings 
at  intervals  sufficiently  close  to  be  effective  in  actually  preventing 
caries. 

The  general  rule  followed  in  this  work  has  been  to  have  most 
patients  come  in  every  two  to  four  weeks  for  a  "treatment." 
Is  that  often  enough?  If  we  are  to  depend  on  this  alone,  it  cer- 
tainly is  not  for  most  people.  If  it  is  supplemented  by  careful 
cleaning,  two  or  three  times  a  day,  by  the  patient,  it  should  be 
very  beneficial,  though  it  is  a  mistake  to  promise  patients  that 


OKAL   PROPHYLAXIS.  417 

decay  will  be  prevented.  It  may  be  prevented;  it  should  be 
retarded  in  proportion  to  the  frequency  of  the  treatments.  The 
principal  difficulty  encountered  in  this  service  is  to  keep  the 
patients  coming.  It's  like  the  old  story  of  our  Arkansas  friend 
whose  house  needed  shingling  —  he  couldn't  do  it  while  it  was 
raining,  and  it  didn't  really  need  it  when  the  weather  was  clear. 
The  dentist  must  have  a  strong  hold  upon  his  patients  to  keep 
them  coming  month  after  month,  year  in  and  year  out.  This  is 
for  many  the  most  difficult  phase  of  the  whole  plan.  A  few  men 
have  apparently  been  very  successful  with  this  plan.  There  is 
some  question  as  to  how  long  they  may  continue.  Most  dentists 
have  not  been  successful  with  more  than  a  very  limited  number 
of  persons. 

It  should  be  understood,  then,  that  we  are  to  employ  all  other 
means  at  our  command  in  treatment,  and  that  we  are  not  to 
endeavor  to  prevent  dental  caries  by  prophylactic  treatments 
alone;  that  we  are  also  to  use  our  utmost  endeavors  to  secure 
the  best  possible  cooperation  on  the  part  of  the  patient  in  the  pro- 
cedures which  will  be  mentioned  under  Mouth  Hygiene.  In 
other  words,  we  will  consider  the  possibilities  of  the  oral  prophy- 
laxis treatment  as  a  part  of  our  daily  serv^ice. 

In  the  prevention  of  caries,  we  have  only  the  beginnings  in 
enamel  and  the  surface  spreading  on  enamel  to  deal  with.  We 
are  not  concerned  with  caries  of  dentin.  We  know  from  our  stud- 
ies of  pathology  that  there  are  three  groups  into  which  we  may 
place  practically  all  beginnings  of  caries:  (1)  Decays  occurring 
in  defects  in  the  enamel  —  pits  and  fissures  in  the  occlusal  sur- 
faces of  bicuspids  and  molars,  buccal  surfaces  of  molars  and 
lingual  surfaces  of  upper  lateral  incisors;  (2)  decays  occurring 
in  the  proximal  surfaces  of  the  teeth ;  (3)  decays  occurring  in  the 
gingival  third  of  buccal,  labial  and  occasionallj^  lingual  surfaces. 
Even  in  the  susceptible  person  all  other  areas  are  practically 
immune  and  require  no  treatment  beyond  the  natural  cleaning 
which  they  receive  in  mastication. 

Let  us  then  consider  these  three  groups  separately  and  see 
in  what  measure  the  prophylactic  treatments  may  be  effective. 

Pit  and  fissure  decays.  These  occur  in  defects  in  surfaces 
which  are  otherwise  kept  clean  by  mastication.  The  defects  are 
such  that  micro-organisms  may  grow  in  them  without  being  dis- 
turbed unless  artificially  removed.  The  acid  formed  in  the 
deeper  portions  is  directly  applied  to  the  enamel.  The  majority 
of  these  decays  occur  early,  soon  after  the  teeth  eru]it.  It  would 
seem  reasonable  to  conclude  that  tliese  decays  would  require  the 


418  SPECIAL    DENTAL,   PATHOLOGY. 

most  aggressive  efforts,  both  as  to  the  detail  and  frequency  of 
the  cleaning,  to  be  successful.  The  dentist  could  hardly  expect 
to  prevent  decay  in  such  positions  by  thorough  cleaning  as  often 
as  once  a  week.  It  would  require  the  earnest  cooperation  of  the 
patient  by  proper  daily  care.  And  the  effort  must  be  continued 
from  the  earliest  time  in  the  childhood  period  of  the  permanent 
teeth  to  and,  for  most  persons,  beyond  even  middle  age;  for 
almost  the  lifetime. 

Even  supposing  that  we  might  be  successful,  is  it  worth  the 
effort,  when  we  can  by  a  simple  filling  operation  so  change  the 
conditions  for  each  such  area  as  to  make  it  self-cleansing  and 
remove  practically  for  all  time,  providing  our  filling  is  well  made, 
the  danger  of  decay  in  the  surface  1  Is  it  not  a  better  procedure, 
from  the  prophylactic  viewpoint,  to  place  a  filling  on  the  first 
slight  appearance  of  decay  and  end  the  matter?  On  the  other 
hand,  the  effort  should  be  made  to  prevent  decays  in  these  defects, 
as  part  of  the  treatments  applied  to  other  areas,  up  to  the  time 
when  decay  first  appears,  but  they  should  then  be  promptly  filled. 
However,  they  certainly  do  not  present  conditions  which  favor 
success  by  the  method  of  prophylactic  treatments  alone,  or  even 
the  combination  of  prophylactic  treatments  and  mouth  hygiene. 

Proximal  decays.  Proximal  decays  occur  on  smooth  sur- 
faces of  enamel  just  to  the  gingival  of  the  contact  point.  The 
majority  of  these  occur  between  the  tenth  and  twenty-fifth  year. 
Normally  the  crest  of  the  septal  gingivae  should  reach  practically 
to  the  contact  point  and  thus  protect  the  proximal  surfaces  from 
beginnings  of  caries.  It  is  only  when  there  has  been  a  slight 
recession  of  this  crest  that  the  opportunity  is  given  for  the  attach- 
ment of  a  colony  of  micro-organisms,  and  a  beginning  of  decay. 
Therefore,  in  any  procedure,  either  by  an  operation  such  as 
filling,  or  in  prophylaxis,  every  care  should  be  exercised  not 
to  injure  the  septal  tissue,  because  injury  usually  results  in 
recession. 

There  is  little  question  but  that  sufficiently  frequent  thor- 
ough cleansing  of  these  areas  will  prevent  decay.  The  required 
frequency  will  vary  with  the  susceptibility  of  the  individual. 
The  technic  of  cleaning  must  be  one  which  will  not  injure  the 
septal  tissue  and  cause,  by  the  necessarily  frequent  repetitions,  a 
gradual  recession  of  that  tissue,  which  would  increase  the  size  of 
the  area  of  liability  on  both  proximating  teeth. 

A  silk  ligature  which  has  been  loaded  with  pumice,  by  first 
moistening  an  inch  or  so  of  it  and  then  pressing  it  in  the  pumice, 
is  oftentimes  the  best  means.    It  has  no  sharp  edge  to  cut  the 


ORAL   PROPHYLAXIS.  419 

gingivae  and  may  be  drawn  back  and  forth  by  being  held  first 
against  the  mesial  surface  of  the  one  tooth,  and  then  against  the 
distal  surface  of  the  other.  A  very  narrow  linpn  tape  may  be 
used  in  the  same  way,  although  it  is  more  apt  to  injure  the  gingi- 
vae. Tapes  with  knots,  etc.,  are  made  for  this  purpose,  but  most 
of  them  are  too  wide.  So  far  as  the  treatment  of  caries  is  con- 
cerned, it  should  be  remembered  that  colonies  of  micro-organisms 
do  not  grow  on  the  enamel  underneath  the  healthy  gum  margin 
and  it  is  therefore  only  necessary  to  polish  the  exposed  surface  of 
the  enamel ;  no  polishing  of  subgingival  spaces  is  indicated.  In 
some  interproximal  spaces,  a  thin  orangewood  stick  may  be  used 
to  advantage ;  in  most  there  is  not  sufficient  room  to  permit  of  its 
use  without  injury  to  the  septal  tissue.  Under  Mouth  Hygiene 
we  will  consider  the  question  of  the  daily  cleaning  of  these  areas 
by  the  patient. 

I  should  say  that  there  seems  to  be  more  reason  why  oral 
prophylaxis  treatments  should  be  applied  for  this  class  of  decays 
than  any  other,  at  the  same  time  there  is  the  greatest  possibility 
of  serious  injury  to  the  soft  tissues. 

Gingival  third  decays.  These  occur  in  fewer  mouths  and 
later  in  life  than  other  decays,  most  of  them  after  the  twentieth 
year.  They  occur  in  positions  which  are  so  easily  reached  by 
the  tooth-brush  in  the  hands  of  the  patient  that  it  would  seem 
unnecessary  for  the  dentist  to  undertake  to  treat  them  by  cleaning 
operations.  It  has  been  satisfactorily  demonstrated  that  the 
patient  can  prevent  these  decays  by  proper  brushing,  and  there 
is  much  room  for  question  as  to  the  eifectiveness  of  cleaning  by 
the  dentist  alone.  In  other  words,  unless  the  dentist  has  the 
cooperation  of  the  patient  by  proper  brushing,  he  will  not  suc- 
ceed ;  and  if  these  areas  are  properly  brushed  by  the  patient,  his 
services  are  unnecessary. 

Cases  which  present  with  beginning  decays  of  very  slight 
depth  in  these  positions  may  be  ground  smooth  and  polished  to 
facilitate  the  cleaning.  Grinding  should  not  be  done  unless  there 
is  an  actual  beginning  of  caries. 

There  is  no  question  but  that  a  monthly  cleaning  by  the 
dentist  will  do  much  toward  keeping  the  patient  active  in  doing 
his  part.  The  monthly  cleaning  by  the  dentist  is  ]irobably  of  less 
real  value  than  the  monthly  criticism  of  the  patient's  care  as  a 
stimulus  to  the  patient  to  take  better  and  continuous  care  of  the 
teeth.  This  is  to  my  mind  the  most  important  feature  of  the  oral 
prophylaxis  treatment  for  dental  caries. 


420  special  dental.  pathology. 

Application  to  diseases  of  the  peridental  membrane.  As 
disease  of  the  peridental  membrane  practically  never  occurs  with- 
out a  preceding  gingivitis,  as  has  been  discussed  fully  in  the 
consideration  of  the  etiology  and  pathology  of  these  diseases,  our 
attention  must  be  given,  in  the  application  or  prophylactic  treat- 
ments, to  the  inflammations  of  the  gingivae.  The  causes  of  the 
common  inflammations  of  the  gingivae  may  be  grouped  under 
three  headings :  (1)  Deposits  of  salivary  calculus;  (2)  Deposits 
of  serumal  calculus;   (3)  Injuries. 

Gingivitis  caused  by  deposits  of  salivary  calculus.  A  knowl- 
edge of  the  conditions  under  which  deposits  of  salivary  calculus 
occur  is  necessary  to  the  employment  of  effective  means  of  pre- 
venting inflammations  from  this  cause.  The  deposit  must  be 
either  prevented  entirely,  or,  if  it  occurs,  it  must  be  removed 
before  injury  is  caused  by  it.  In  the  consideration  of  the  subject, 
it  has  been  shown  that  salivary  calculus  is  deposited  only  (1) 
when  calco-globulin  is  being  secreted  with  the  saliva,  and  (2) 
when  the  local  opportunity  —  an  irregular  surface  for  lodgment 
—  exists.  The  deposit  seldom  occurs  in  the  mouths  of  children, 
but  usually  in  adults,  and  increasing  with  greater  age.  It  has 
been  shown  that  the  outpouring  of  the  calco-globulin  is  in  parox- 
ysms a  few  hours  after  a  meal  and  these  may  be  repeated  daily 
or  even  after  each  meal.  The  deposit  occurs  most  frequently  on 
the  lingual  surfaces  of  the  lower  incisors,  where  caries  practi- 
cally never  occurs,  and  on  the  buccal  surfaces  of  the  upper  molars 
in  the  gingival  third.  The  deposit  is  very  soft  when  first  laid 
down  —  so  soft  that  it  may  be  easily  brushed  away ;  it  gradually 
hardens  so  that  within  twenty-four  hours  it  may  be  so  hard  that 
it  can  not  be  easily  removed  with  a  brush.  It  may  be  easily 
removed  with  the  tooth-brush  and  plain  water,  if  the  brushing  is 
thoroughly  done  twice  a  day.  It  would  seem,  therefore,  that  the 
patient  ought  to  prevent  these  deposits ;  but  as  a  matter  of  fact, 
most  of  them  will  fail  in  part,  either  by  errors  in  the  manipula- 
tion of  the  brush,  or  because  of  omissions  in  the  twice  a  day 
routine.  Therefore,  a  considerable  percentage  of  our  people 
should  come  more  or  less  frequently  —  the  interval  to  be  adjusted 
to  the  individual  —  for  the  removal  of  these  deposits  and  the 
polishing  of  the  surfaces  on  which  they  have  occurred.  The 
effort  should  be  to  so  manage  these  cases  that  there  will  be  the 
least  possible  blunting  of  the  crests  of  the  gingivae;  for  the 
broader  the  shelf  which  these  offer,  the  greater  will  be  the  oppor- 
tunity offered  for  the  accumulation,  and  likewise  the  greater  the 
difficulty  in  its  removal  with  the  brush. 


ORAL.  PROPHYLAXIS.  421 

Gingivitis  caused  hy  deposits  of  serumal  calculus.  These 
deposits  occur  on  the  enamel  under  the  free  margin  of  the  gingi- 
vae, or  on  the  cementum  in  a  pus  pocket;  never  on  an  exposed 
surface.  They  almost  never  occur  in  the  mouths  of  children,  and 
usually  in  the  mouths  of  persons  beyond  twenty  years  of  age. 
As  with  salivary  calculus,  the  deposits  should  either  be  pre- 
vented, or  removed  before  serious  inflammation  is  caused.  Calco- 
globulin  is  likely  to  be  poured  out  into  the  subgingival  spaces 
contemporaneously  with  its  secretion  with  the  saliva,  in  parox- 
ysms a  few  hours  after  a  meal.  It  is  also  soft  when  first  depos- 
ited, but  is  not  so  located  that  it  may  be  removed  by  brushing. 
However,  there  is  no  doubt  but  that  the  frequent  washing  of  the 
subgingival  spaces  with  a  jet  of  water  from  the  syringe  will  b^ 
of  much  benefit  in  retarding  the  accumulation.  The  principal 
advantage  in  both  brushing  and  washing  will  be  in  keeping  the 
gingiva  in  the  highest  degree  of  health,  thus  reducing  to  the  mini- 
mum the  conditions  conducive  to  the  deposit. 

Here  again,  however,  most  patients  will  fail  in  considerable 
part  through  errors  in  the  use  of  the  syringe  or  neglect,  and  their 
care  should  be  supplemented  by  the  service  of  the  dentist.  "Regu- 
lar intervals  should  be  determined,  after  a  study  of  the  particular 
case,  and  accumulations  should  be  removed.  In  the  subsequent 
polishing  of  the  areas,  great  care  should  be  taken  not  to  injure 
the  gingivas. 

The  same  rules  of  treatment  apply  to  cases  in  which  there 
has  been  a  detachment  of  the  peridental  membrane  followed  by  a 
deposit  on  the  cementum,  to  prevent,  as  far  as  may  be,  the  recur- 
rence of  the  deposit  and  the  extension  of  the  injury. 

Gingivitis  caused  hy  injuries.  For  traumatic  gingivitis  — 
the  oral  prophylaxis  treatment  is  not  indicated,  except  possibly 
secondarily.  In  all  such  cases  the  prevention  of  the  recurrence 
or  continuation  of  the  trauma  should  have  first  attention.  If 
this  can  be  done  the  gingivitis  will  usually  disappear  unless  some- 
thing has  occurred  secondarily  which  would  keep  up  the  inflam- 
mation. In  all  such  cases  the  areas  should  be  thoroughly  scaled 
and  polished,  a  record  made,  and  the  area  watched  and  treated 
again,  if  necessary. 

Summary. 

In  all  of  this  treatment  of  oral  prophylaxis,  I  wish  to  very 
strongly  emphasize  the  fact  that  there  should  always  be  a  definite 
indication  for  the  cleaning  and  polishing  for  each  part  or  each 
area  of  each  tooth  which  is  so  treated.     It  should  be  remembered 


422  SPECIAL   DENTAL    PATHOLOGY. 

tliat  most  of  the  exposed  portion  of  the  tooth  crown  is  so  thor- 
oughly cleansed  in  mastication  that  it  requires  no  artificial  clean- 
ing. I  have  stated  that  the  pit  and  fissure  decays  will  usually  be 
best  cared  for  by  fillings.  There  remain,  then,  for  most  people : 
the  proximal  surfaces  in  which  decays  occur  mostly  during  the 
period  from  ten  to  twenty-five  years  of  age;  the  gingival  thirds 
of  buccal  and  labial  surfaces  in  which  most  decays  occur  after  the 
twentieth  year ;  the  gingival  thirds  of  the  lingual  surfaces  of  the 
lower  incisors  and  buccal  surfaces  of  molars  on  which  deposits  of 
salivary  calculus  occur,  usually  in  the  mouths  of  adults ;  and  the 
subgingival  enamel,  on  which  deposits  of  serumal  calculus  occur, 
usually  after  the  twentieth  year. 

The  greatest  care  should  be  taken  in  all  of  this  service  to 
avoid  injury  to  the  gingiva}.  I  would  consider  it  definitely  wrong 
to  polish  the  enamel  of  the  subgingival  spaces  in  the  mouths  of 
children  as  a  part  of  a  routine  treatment,  because  there  is  no  indi- 
cation for  so  doing,  and  the  frequent  repetition  of  it  is  practically 
certain  to  injure  the  gingivae.  Likewise  there  is  too  much  danger 
of  injuring  the  sex)tal  tissue  to  justify  the  indiscriminate  practice 
of  polishing  all  proximal  surfaces  every  few  weeks.  Discretion 
must  be  used  in  selecting  cases. 

Tn  the  mouths  of  few  patients  are  we  justified  in  following 
out  the  most  thorough  and  complete  prophylactic  treatments. 
Some  patients  need  areas  polished  to  prevent  caries,  others  for 
salivary  calculus,  still  others  for  serumal  calculus.  Each  gener- 
ally involves  different  areas.  It  does  not  seem  rational,  there- 
fore, that  we  should  scour  and  polish  every  part  of  the  enamel  of 
every  tooth,  as  some  men  have  suggested,  but  we  should  apply 
treatment  for  each  individual  to  the  positions  which  our  best 
judgment  tells  us  it  is  indicated. 


MOUTH    HYGIENE.  423 


H 


MOUTH  HYGIENE 

I  ILLUSTRATIONS:    FIGURES  477-600. 

YGIENE  is  defined  as  that  branch  of  medical  science  which 
relates  to  the  preservation  and  improvement  of  health,  both 
in  individuals  and  in  communities.  It  has  no  special  relation  to 
particular  diseases,  as  is  the  case  with  prophylaxis. 

POPULAE   EDUCATION. 

Mouth  Hygiene  should  include  all  measures  employed, 
mostly  by  each  individual  for  himself,  under  the  direction  of  the 
dentist,  to  keep  the  mouth  in  the  healthiest  possible  condition. 
Every  one  should  know  what  rules  should  be  followed  and  what 
results  may  be  expected.  There  is  presented  a  great  problem  in 
education;  in  spreading  the  knowledge  that  many  serious  dis- 
eases which  result  from  mouth  conditions  may  be  prevented ;  that 
the  more  common  diseases  of  the  mouth,  such  as  the  decay  of  the 
teeth  and  the  inflammations  of  the  peridental  membrane,  may  be 
largely  controlled  by  simple  methods  of  cleaning  at  regular 
intervals. 

Let  us  look  for  a  moment  at  the  larger  educational  problem ; 
later  we  will  consider  the  technic  of  cleaning  the  mouth.  Physi- 
cians, dentists  and  nurses  are  the  teachers  who  must,  in  their 
daily  contact  with  our  people,  educate  them  in  such  matters. 
However,  material  aid  has  come  and  will  continue  to  come  from 
other  sources.  The  most  noteworthy  single  effort  to  this  end  has 
found  expression  in  the  Forsyth  Memorial  in  Boston.  A  fund 
of  two  million  dollars  has  been  devoted  to  the  erection  and  endow- 
ment of  a  splendid  building  for  the  purpose  of  caring  for  the 
mouths  of  the  school  children  of  poor  families  in  Boston,  and  for 
the  larger  purpose  of  educating  the  general  public  to  the  value  of 
clean  and  healthy  mouths.  The  Forsyth  Memorial  is  not  to  be 
considered  a  charitable  institution,  but  an  educational  one  —  an 
institution  which  will  not  only  prove  the  value  of  the  proper  care 
of  the  mouth  by  demonstrations  and  clinical  records,  but  will  also 
be  so  directed  and  used  ns  to  eventually  place  the  responsibility 
for  the  guardianship  of  the  healthy  body  and  the  healthy  mouth, 
especially  of  our  children,  upon  the  state  and  nation.     The  posi- 


424  SPECIAL   DENTAL   PATHOLOGY. 

tion  is  taken  that  it  is  quite  as  much  the  duty  of  the  state 
to  look  after  the  health  of  our  children  as  it  is  to  look  after  their 
education. 

Attention  has  been  called  many  times  to  the  fact  that  our 
Government  has  expended  enormous  sums  of  money  in  studying 
those  problems  involved  in  the  preservation  of  the  health  of  our 
domestic  animals,  and  in  the  raising  of  crops,  because  these  are 
economic  problems ;  but  little  eif  ort  has  been  made  to  study  and 
prevent,  or  to  teach  our  people  how  to  prevent,  the  diseases  which 
carry  off  untold  thousands  of  our  population  every  year.  The 
commercial  spirit  of  the  age  has  led  us,  not  only  as  a  nation,  but 
as  individuals,  to  neglect  health  in  order  to  get  ahead  financially. 
We  should  realize  that  there  is  greater  economy  in  the  growth  and 
proper  development  of  healthy  individuals ;  that  each  child  who 
is  strong  and  well  soon  becomes  one  of  the  units  in  the  develop- 
ment of  those  things  toward  which  the  human  race  is  set ;  he  is  a 
producer ;  while  the  child  who  is  weak  and  sickly  becomes  more 
and  more  one  of  the  world's  cares,  a  consumer  who  does  not  pro- 
duce, and  often  one  who  may  become  a  destroyer  by  entering  the 
class  of  criminals  and  mental  defectives. 

We  must  look  forward  to  the  day  when  our  Government  will 
devote  itself  to  the  study  of  problems  involved  in  the  preserva- 
tion of  the  health  of  our  people ;  when  we  shall  have  a  national 
Department  of  Health,  which  will  consider  human  problems  in 
much  the  same  manner  as  the  Department  of  Agriculture  has 
studied  and  developed  methods  for  the  improvement  of  stock  and 
crops. 

Much  information  regarding  mouth  conditions  has  been 
gained  during  recent  years  from  the  examination  of  the  mouths 
of  our  school  children  in  many  cities.  Most  of  this  work  has  been 
performed  b^^  dentists  on  their  own  initiative  or  under  the  direc- 
tion of  our  various  dental  organizations.  It  is  gradually  becom- 
ing better  systematized  and  its  importance  recognized  by  civic 
authorities.  Several  States  employ  dentists  as  regular  staff 
members  of  the  various  eleemosynary  institutions,  and  a  large 
number  of  cities  have  recognized  the  value  of  dental  service  by 
making  appropriations  as  a  regular  item  in  their  annual  budgets. 

It  is  my  object  to  present  facts  lying  at  the  basis  of  practical 
mouth  hygiene.  Our  people  should  have  a  better  and  broader 
knowledge  of  the  conditions  of  the  development  of  certain  of  the 
diseases  of  the  mouth,  and  the  means  of  preventing  them.  I  have 
already  said  that  within  my  personal  observation  the  loss  of  teeth 
caused  by  deposits  of  salivary  calculus  has  been  diminished  as 


MOUTH    HYGIENE.  425 

much  as  seventy-five  per  cent  by  wider  knowledge  of  the  neces- 
sary personal  care.  We  ought  soon  to  reduce  this  so  that  only  a 
limited  number  of  persons  would  be  so  injured.  The  plans  of 
daily  cleaning  of  teeth  are  found  to  be  perfectly  dependable  in 
preventing  injuries  by  salivary  calculus,  as  well  as  diseases  which 
depend  upon  unclean  areas  in  the  mouth  for  their  inception  and 
progress. 

A  good  understanding  of  the  cause  of  a  disease  is  necessary 
to  the  adaptation  of  means  for  its  prevention.  Much  is  yet  to  be 
done  in  the  instruction  of  dentists,  as  well  as  the  laity,  regarding 
the  causes  of  diseases  of  the  soft  tissues  of  the  mouth,  before  we 
can  be  sure  of  the  virtue  of  proposed  means  for  their  prevention. 
Already  the  active  teaching  of  the  public  as  to  what  individuals 
should  do  in  the  cleaning  of  their  teeth  as  a  matter  of  intelligent 
care  of  their  persons,  seems  to  have  begun  in  earnest. 

In  a  paper  on  Constitutional  Diseases  Secondary  to  Local 
Infections,*  Dr.  C.  H.  Mayo  has  this  striking  sentence  used  near 
the  close  of  his  remarks  on  the  prevention  of  disease:  ''The 
difference  between  the  knowledge  of  the  layman  and  the  medical 
attendant,  including  the  dentist,  should  not  be  too  great.  Medical 
progress  may  be  stayed  from  time  to  time  that  the  lajTnan  may  be 
educated  to  certain  truths  of  health ;  that  he  must  first  know,  then 
desire,  and  then  demand  proper  health  conditions." 

The  work  now  being  done  in  the  instruction  of  our  peo- 
ple regarding  the  maintenance  of  healthy  mouth  conditions  is 
intended  to  bring  them  closer  to  the  dentist  in  their  knowledge  of 
such  things,  and  in  this  way  assist  in  bringing  about  better 
cooperation  between  dentists  and  patients. 

CAKE    OF    THE    MOUTH. 

Temporaey  TEETH.  The  care  of  the  mouth  should  begin 
when  the  first  of  the  deciduous  teeth  erupt.  Previous  to  tbe 
eruption  of  the  teeth,  the  mouth  of  the  baby  needs  no  care  for 
cleanliness,  as  a  rule.  Some  years  ago,  it  was  the  practice  of 
many  physicians  to  direct  that  the  mouth  of  the  baby  should  bo 
swabbed  with  a  piece  of  gauze,  wet  with  boric  solution,  after 
each  nursing.  There  seems  to  be  no  indication  for  this,  and  I 
feel  that  the  practice  should  be  condemned.  Care  should  be 
exercised,  however,  to  have  the  breast  or  the  rubber  nipple  clean 
before  the  baby  nurses,  as  a  prophylactic  measure  against  a  sore 
mouth. 

The  care  of  the  deciduous  teeth  should  l)e  along  the  same 

•  Dental  Eeview,  Vol.  27,  1913,  p.  281. 
39 


426  SPECIAL   DENTAL   PATHOLOGY. 

general  lines  as  for  the  permanent  teeth,  except  that  during  the 
period  of  the  presence  of  the  deciduous  teeth,  as  well  as  during 
the  childhood  period  of  the  permanent  teeth,  it  is  unusual  to  have 
deposits  of  either  salivary  or  serumal  calculus,  and  therefore,  as 
the  rule,  no  measures  need  be  employed  to  prevent  these  accumu- 
lations. If,  however,  the  examination  should  reveal  deposits, 
care  to  eliminate  these  should  at  once  be  instituted.  Likewise, 
less  consideration  need  be  given  to  the  soft  tissues  during  this 
same  time,  as  they  are  not  often  seriously  involved. 

It  is  to  prevent  or  retard  the  progress  of  dental  caries  dur- 
ing childhood  that  the  mouth  should  receive  attention.  As  soon 
as  the  first  deciduous  teeth  have  erupted,  the  use  of  the  tooth- 
brush should  begin.  The  brush  itself  should  be  of  the  smallest 
size  obtainable;  soft  enough  not  to  injure  the  gums,  yet  stiff 
enough  to  be  effective  in  cleaning.  (See  Figure  477.)  The 
motions  of  the  brush  should  be  the  same  as  for  the  adult,  as  will 
be  described  in  detail  later. 

In  the  beginning,  the  child's  mouth  should  be  cared  for  liy 
the  mother  or  nurse,  and  the  brushing  should  be  done  immedi- 
ately after  each  meal.  As  the  child  grows  older,  it  should  be 
taught  to  do  the  brushing,  under  careful  supervision,  until  it  has 
acquired  the  necessary  skill  and  has  formed  the  habit  of  brush- 
ing the  teeth  as  the  first  duty  after  each  meal.  Nothing  is  of 
greater  importance  to  the  future  health  of  the  mouth  than  for  the 
child  to  form  this  habit  of  prompt  and  regular  brushing  of  the 
teeth.  The  child  that  forms  such  a  habit  will  come  to  appre- 
ciate the  comfort  of  a  habitually  clean  mouth  and  will  not  be 
likely  to  neglect  the  cleaning  in  after  years. 

The  dentist  should  never  overlook  an  opportunity  to  impress 
the  importance  of  saving  the  deciduous  teeth  in  order  to  avoid, 
as  far  as  possible,  the  danger  of  disease  and  irregularities  of  the 
permanent  teeth,  which  often  interfere  with  the  proper  develop- 
ment of  the  face.  It  is  probable  that  nothing  is  more  effective  in 
gaining  and  holding  the  interest  of  both  parents  and  child  in  the 
care  of  the  mouth  than  to  direct  their  attention  to  dangers  which 
beset  the  permanent  teeth  if  the  temporary  teeth  are  neglected. 
In  the  past  our  people  have  not  been  alarmed  at  an  extensive 
decay,  or  an  exposed  pulp,  or  an  abscess  of  a  deciduous  tooth, 
because,  they  reason,  this  tooth  will  be  lost  in  a  year  or  so,  any- 
how. If,  however,  these  conditions  are  recognized  as  a  menace 
to  the  permanent  teeth,  and  particularly  if  the  symmetry  of  the 
face  is  endangered,  the  case  takes  on  a  more  serious  aspect,  and 


MOUTH    HYGIENE.  427 

the  active  cooperation  of  all  concerned  is  more   likely  to  be 
obtained. 

Technic  of  cleansing  the  mouth. 

In  cleansing  the  mouth,  one  should  have  plenty  of  water  — 
running  water  preferred  —  and  in  addition  to  a  suitable  tooth- 
brush there  is  often  some  advantage  in  the  use  of  toothpicks, 
rubber  bands,  floss  silk,  a  rubber  bulb  syringe,  and,  for  those 
who  wear  artificial  teeth,  special  plate  brushes.  The  dentist 
should  have  each  of  the  above  to  show  to  patients.  The  move- 
ments of  the  brush,  the  liability  of  missing  some  certain  teeth, 
and  the  training  necessary  to  the  best  use  of  the  brush  should 
often  be  illustrated  by  actual  use. 

I  am  especially  partial  to  running  water  for  cleaning  the 
teeth.  It  ma}^  be  arranged  to  be  running  from  the  faucet  and 
out  of  the  basin,  carrying  away  all  debris,  and  in  this  way  keep- 
ing the  water  clean.  Water  that  is  a  little  warm  is  much  pleas- 
anter  than  either  cold  or  very  warm  water.  In  the  absence  of 
running  water  an  ordinary  pan  or  wash-basin  will  serve  the 
purpose  very  well.  It  is,  however,  quite  a  point  to  have  plenty 
of  water. 

The  mouth  should  first  be  thoroughly  rinsed  with  water,  by 
taking  a  considerable  quantity  into  the  mouth,  closing  the  teeth 
and  lips,  and  forcing  the  water  back  and  forth  through  spaces 
between  the  teeth.  When  thoroughly  done,  this  is  one  of  the 
most  effective  means  of  cleansing  that  portion  of  these  spaces 
which  can  not  be  reached  with  the  brush. 

The  tooth-brush.  The  brush  is  of  more  importance  tha?! 
all  else  in  the  cleaning  of  the  mouth.  The  brush  should  be  care- 
fully selected.  Most  tooth-brushes  are  too  large  to  permit  of 
sufficiently  free  movement  in  the  mouth.  Brushes  shown  in 
Figures  480,  481,  482,  488  and  497  are  too  large.  A  brush  about 
the  size  of  those  sold  as  a  youth's  brush  is  to  be  preferred.  (See 
Figures  479,  483,  484,  487,  490,  491,  493,  494  and  495.)  The 
bristles  should  not  be  too  closely  set;  there  should  be  nearly  as 
much  space  between  the  rows  of  bristles,  as  is  occupied  by  the 
bristles.  (See  Figures  477  to  480.)  A  brush  having  the  bristles 
rather  deeply  notched  crosswise  is  very  desirable.  (See  Figure 
496.)  As  to  the  stiffness,  each  person  should  select  a  brush 
which  is  as  stiff  as  may  be  used  vigorously  on  the  gums  without 
causing  pain.  Such  brushes  are  usually  marked  "mediniii." 
A  new  brush  is  always  somewhat  stiffer  than  it  will  be  after  it 
has  been  used  for  a  time.     In  buying,  one  should  rather  consider 


428  SPECIAX,   DENTAL   PATHOLOGY. 

what  the  brush  will  be  after  a  little  use.  While  the  brush  is  new 
the  bristles  may  be  softened  by  soai:ing  the  brush  for  a  few  min- 
utes in  warm  water  before  using.  Persons  who  use  too  stiff  a 
brush  are  apt  to  avoid  brushing  the  soft  tissues,  and  lose  that 
which  is  of  great  value  in  cleaning,  i.  e.,  the  stimulation  of  the 
gingivae. 

For  many  persons,  special  brushes  should  be  selected  to 
meet  the  peculiar  conditions  presenting  in  their  mouths.  In 
some  mouths  it  is  almost  impossible  to  clean  about  the  third 
molars,  either  upper  or  lower,  unless  the  bristles  near  the  end  of 
the  brush  are  very  short.  In  many  mouths,  when  open,  the 
ramus  of  the  lower  jaw  is  so  close  to  the  buccal  surfaces  of  the 
upper  molars  as  to  interfere  with  the  movements  of  the  brush 
which  are  necessary  to  clean  these  surfaces,  unless  the  bristles 
are  very  short.  (See  Figures  493  and  494.)  Those  brushes 
with  a  tuft  of  very  long  bristles  near  the  end  are  generally  to 
be  avoided,  as  they  fold  back  against  the  handle,  when  the  brush 
is  carried  far  back  in  the  mouth,  and  do  little  or  no  cleaning. 
(See  Figure  497.)  The  end  bristles  should  be  short  enough  so 
that  there  will  be  sufficient  room  between  the  teeth  and  the  cheek 
for  the  brush  to  be  moved  freely.  Some  of  the  brushes  on  the 
market,  which  have  the  long  tuft  of  bristles  at  the  end,  make 
very  good  brushes  if  these  long  bristles  are  cut  short  with  a  pair 
of  scissors.  (See  Figures  481  and  482.)  In  some  mouths  there 
is  insufficient  room  to  the  buccal  of  the  upper  third  molars  for  a 
brush  with  the  shortest  possible  bristles.  In  such  cases,  a  brush 
with  a  small  tuft  of  bristles  at  the  end  may  be  carried  directly 
across  the  occlusal  surface,  with  the  tuft  reaching  over.  The 
tuft  may  thus  be  moved  along  the  buccal  and  also  the  distal 
surface.     (See  Figure  496.) 

For  some  persons,  whose  lower  front  teeth  are  inclined 
lingually,  a  brush  with  a  bend  in  the  handle  (the  back  side  of  the 
handle  being  convex)  will  make  it  possible  to  reach  the  lingual 
surfaces  of  these  teeth  to  better  advantage.  (See  Figures  491 
and  492.)  *^  "^^ 

The  dentist  should  examine  each  mouth  as  to  the  available 
space  for  the  brush  in  various  parts,  especially  about  the  third 
molars  and  the  lingual  of  the  lower  incisors.  He  should  also 
note  whether  it  is  best  to  have  the  jaws  apart  or  the  teeth  in 
occlusion.  In  many  mouths  the  buccal  surfaces  of  the  upper 
second  and  third  molars  can  be  cleaned  more  effectively  with 
the  jaws  closed.  The  dentist  should  give  directions  as  to  the 
style  of  brush  to  be  used.     In  this,  there  should  be  certain  stan- 


Fifi.  477, 


Ki(i.    tTN. 


Fm.  4  7!t. 


Fig.  480. 


Figs.  477,  47S.  479,  ISO.  Four  toolli  l.nislu's,  actual  sizes,  I'or  liahy.  cliiM.  vcmtli 
and  adult.  All  tour  have  tli.'  luistlcs  set  siitlicicntly  far  apart  and  the  brushos  are 
geiienilly  of  yood  form.  'I'hc  hriisli  in  Kijjnrc  47H.  ordinarily  sold  a.s  a  youth's  hI/.i'. 
is  by  far  the  best  size  for  most  adults,  as  tlicrc  is  better  ojiportunity  to  manipulate 
it  in  the  mouth.  While  some  i)ersons  may  use  a  brush  as  lar^'e  a.s  Figure  480,  it  is 
too  large  to  permit  of  proper  uunements  in  most   months. 

♦39 


Fifi.  4S1, 


Fig.  482. 


Figs.  481,  482.  Two  tooth-brushes,  actual  size.  The  brush  shown  in  Figure  481 
has  the  bristles  well  spaced  Tho  tuft  of  longer  bristles  at  the  end  reduces  its 
effectiveness.  (See  Figure  497.)  If  these  end  bristles  are  cut  off,  as  shown  in 
Figure  482,  it  makes  a  nuicli  better  lirush.  Both  of  these  brushes  are  too  large  for 
most  mouths. 


Fig.  483. 


Fig.  484. 


Fig.  4s,'}. 


Figs.  483,  484,  485.  Thrrr  tootli  lnuslirs.  mc'IumI  si/r.  Fimirr  483  is  :i  spU'iKliil 
brush.  This  is  tho  best  form  for  most  ])(msoiis.  l'ij,Mui'  4s  I  is  ;i  similar  brush  wifli 
a  groattT  anglo,  and  is  especially  yood  for  ri-achini,^  the  linjiiial  surfaces  of  the  lower 
incisors.  (See  Figure  4!tL'.)  The  siiMciiij,'  of  the  bristles  in  l''i;,rnri'  48."(  is  very  good, 
but,  the  bristles  are  a   little  ton  long. 


Fig.  4S6. 


Fig.  486  shows  the  brush  (handle  cut  off)  in  the  proper  position  on  the  gum  for 
the  movement  over  the  gingiva-  and  buccal  surfaces  of  the  lower  teeth.  The  movement 
should  always  be  from  the  gums  over  the  gingivfp  and  teeth;  this  tends  to  keep  the 
crests  of  the  gingivie  thin,  while  the  opposite  movement  tends  to  blunt  the  crests  and 
thus  give  ojiportunity  for  Indgiiionts. 


MOUTH    HYGIENE.  429 

dard  types  which  will  be  right  for  most  people,  and  others  to  suit 
special  requirements. 

Movements  of  the  brush.  Each  person  should  foinn  the 
habit  of  following  a  definite  routine  of  brushing.  It  makes  no 
particular  difference  where  one  begins  or  ends,  if  the  habit  is 
foiTued  of  following  the  same  routine  at  each  brushing.  When 
one  has  once  formed  such  a  habit,  there  will  be  little  danger  of 
missing  any  part  of  the  mouth.    The  following  plan  is  suggested : 

After  the  brush  has  been  held  in  the  water  for  a  moment., 
the  end  should  be  carried  fully  back  to  the  last  molar  tooth,  or 
beyond  it  when  possible,  on  the  left  side  of  the  lower  jaw.  The 
ends  of  the  bristles  of  the  brush  should  be  placed  against  the 
gums  over  the  roots  of  the  teeth,  and  then,  with  either  a  straight 
or  a  twisting  motion  of  the  wrist,  the  brush  should  be  swept  over 
the  teeth  toward  their  occlusal  surfaces.  (See  Figure  486.) 
This  should  be  done  several  times.  One  should  learn  to  repeat 
this  motion  quickly  with  a  twisting  of  the  wrist,  and  while  so 
doing,  gradually  bring  the  brush  forward  to  the  incisor  region. 
Then,  with  fresh  water,  the  brush  should  be  carried  back  in  the 
same  way  on  the  lower  right  side  and  the  motions  repeated,  until 
all  of  the  buccal  and  labial  gum,  gingivae  and  the  buccal  sur- 
faces of  the  teeth  have  been  cleaned.  These  motions  should  be 
repeated  for  the  upper  jaw,  the  brush  being  first  placed  far  back 
on  the  gum  of  the  left  side,  and  swept  over  the  gingivae  and  teeth 
in  the  direction  of  their  occlusal  surfaces.  (See  Figures  493, 
494  and  495.) 

Particular  attention  is  called  to  the  fact  that  the  motion  of 
the  brush  is  first  upon  the  gums,  next  over  the  gingivae,  next  over 
the  buccal  surfaces  of  the  teeth  to  the  occlusal  margins  and  off. 
Then  the  brush  should  be  lifted  and  replaced  upon  the  gums  as 
before,  and  again  swept  over  the  gingivas  and  the  teeth,  continu- 
ing until  their  occlusal  surfaces  are  passed.  One  may  soon  learn 
to  make  these  motions  very  rapidly. 

As  previously  mentioned  it  will  be  difficult  in  many  mouths 
to  reach  the  gum  overlying  the  upper  third  molars,  or  even  the 
buccal  surfaces  of  the  crowns  of  these  teeth,  on  account  of  tlie 
little  space  between  them  and  the  ramus  of  the  lower  jaw  and 
the  cheek,  and  a  special  ])rush  will  be  necessary.  (See  Figures 
493,  494  and  496.) 

In  those  mouths  in  wliich  the  ])uccal  surfaces  of  the  back 
teeth  can  be  more  conveniently  reached  with  the  jaws  closed,  the 
brush  should  be  used  with  a  downward  swoe]i  from  the  upper 
gum  over  the  buccal  surfaces  of  the  upper  ti'cth,  imd  a  return 

S9b 


430  SPECIAL   DENTAL    PATHOLOGY. 

upward  sweep  from  the  lower  gum  over  the  buccal  surfaces  of 
the  lower  teeth. 

Some  persons  seem  not  to  effectively  clean  the  gingival  thirds 
of  the  buccal  surfaces  of  the  teeth  with  the  upward  and  down- 
ward movements  just  mentioned.  This  will  be  more  likely  to  be 
so,  if  for  any  reason  the  buccal  gingivae  have  lost  their  knife-like 
edge  and  are  rather  thick  and  blunt.  Such  areas  should  be 
cleaned  with  a  forward  and  backward  motion  of  the  brush,  about 
half  of  the  width  of  the  brush  being  over  the  gingiva?.,  the  other 
half  over  the  buccal  surfaces  of  the  teeth.  I  have  occasionally 
seen  some  injury  to  the  septal  tissue  by  the  use  of  this  movement 
with  too  stiff  a  brush. 

To  go  over  the  surfaces  in  each  region  three  or  four  times, 
with  the  up  and  down  motions,  gradually  bringing  the  brush 
forward  to  the  front  of  the  mouth,  is  sufficient  to  do  all  that  can 
l)e  done  with  the  brush.  These  motions  will  bring  the  bristles 
in  contact  with  every  part  of  the  tooth  crown  and  through  the 
embrasures  as  deeply  as  they  can  be  readily  forced. 

The  motions  for  the  lingual  surfaces  of  the  lower  molars 
should  be  practically  the  same  as  those  for  the  buccal  surfaces, 
but  they  are  more  difficult  to  make  correctly.  (See  Figures  489 
and  490.)  The  same  may  be  said  of  the  lingual  surfaces  of  the 
upper  molars.  For  both  lowers  and  uppers,  the  brush  must  be 
held  somewhat  obliquely  to  the  line  of  the  arch  and  most  of  the 
brushing  done  with  the  bristles  toward  the  end  of  the  brush. 

The  brushing  of  the  lingual  surfaces  of  the  incisors,  both 
lower  and  upper,  is  best  done  with  an  endwise  motion  of  the 
brush.  (See  Figures  491  and  492.)  The  handle  of  the  brush 
should  project  out  of  the  mouth  parallel  to  the  length  of  these 
teeth.  The  brush,  while  held  in  this  position,  should  be  placed 
on  the  gum  and  the  motion  of  the  brush  should  be  over  the  gum, 
gingivae  and  teeth.  The  brush  should  then  be  lifted,  replaced 
on  the  gum,  and  the  motion  over  gum,  gingivae  and  teeth  repeated 
several  times.  This  will  tend  to  keep  the  crests  of  the  gingivae 
thin,  while  brushing  with  the  opposite  motion  would  tend  to 
reduce  the  height  of  the  gingivae  and  thicken  the  crests.  The 
brush  may  be  moved  from  side  to  side  across  the  lingual  sur- 
faces of  the  teeth  close  to  the  gum,  for  the  removal  of  deposits 
which  may  have  been  missed  by  the  other  movement.  This 
brushing  should  include  the  gum.  It  is  well  to  call  the  attention 
of  patients  to  the  fact  that  they  should  feel  the  brush  on  the  gum. 

If  there  are  defects  in  occlusal  surfaces,  these  should  also  be 
thoroughly  brushed.    As  a  rule  these  surfaces  are  so  well  cleaned 


MOUTH    HYGIENE.  431 

in  mastication  that  they  require  little  brushing.  If  there  are  no 
defects,  or  if  the  pits  and  grooves  have  been  made  smooth  by 
filling,  they  should  need  no  brushing. 

Teeth  which  are  not  used  normally  in  mastication,  either  on 
account  of  the  loss  of  opposing  teeth,  or  on  account  of  a  sensitive 
or  tender  tooth,  should  be  very  thoroughly  brushed  on  all  sur- 
faces, as  the  cleaning  of  mastication  must  always  be  regarded  as 
the  principal  factor  in  mouth  cleanliness. 

Cake  of  the  brush.  After  using,  the  brush  should  be  thor- 
oughly rinsed  with  water  and  hung  up  to  dry.  If  the  brush 
selected  does  not  have  a  hole  in  the  handle,  a  brass  screw-eye  of 
proper  size  makes  a  very  good  holder.  The  eye  should  be  large 
enough  so  that  the  handle  can  be  slipped  through  it,  the  bristles 
being  up. 

After  brushing,  the  mouth  should  be  quite  thoroughly  rinsed 
with  several  mouthfuls  of  water.  It  is  well  also,  to  rinse  the 
mouth  a  number  of  times  while  doing  the  brushing.  The  more 
effective  rinsing,  when  the  water  is  taken  into  the  mouth,  is  done 
by  closing  the  teeth  firmly  and  forcing  the  water  back  and  forth 
from  lingual  to  buccal  a  number  of  times. 

Until  one  has  certainly  formed  the  habit  of  brushing  the 
teeth  systematically  in  accordance  with  the  plan  mentioned,  or 
any  similar  one  which  includes  all  positions  which  need  to  be 
brushed,  he  should  stand  before  a  mirror  and  watch  every  move- 
ment to  see  that  the  brushing  is  thoroughly  done.  Even  those 
persons  who  take  the  utmost  care  in  the  brushing  of  their  teeth 
are  liable  to  miss  one  or  more  places,  and  the  dentist  should,  in 
his  examinations,  be  constantly  on  the  lookout  for  such  neglected 
places  and  call  the  attention  of  patients  to  them. 

The  toothpick.  The  toothpick  is  designed  to  cleanse  the 
interproximal  space  and  the  proximal  surfaces  of  the  teetli. 
Normally  the  septal  gingiva  should  fill  the  septal  space  com- 
pletely to  the  contact  point,  so  that  there  will  be  no  opportunity 
for  food  to  lodge.  Decay  of  proximal  surfaces  usually  begins 
only  when  the  septal  gingiva  has  receded  a  little.  AVhen  it  has 
receded,  some  effective  means  must  be  employed  for  cleaning  the 
surfaces  of  the  teeth  between  the  contact  point  and  the  crest  of 
the  gingiva.  This  cleaning  may  be  done  with  a  toothpick,  by 
passing  the  thin  flat  end  of  the  pick  between  the  teeth  and  rub- 
bing the  surface,  first  of  one  tooth,  then  the  other.  A  toothpick 
made  of  quill,  or  as  thin  a  wooden  pick  as  may  be  had,  and  made 
of  a  very  close-fibered  wood,  having  a  smooth  hard  surface  with- 
out slivers  or  splinters,  will  be  the  best  to  use.     If  a  quill  pick  is 


432  SPECIAL   DENTAL,   PATHOLOGY. 

used,  the  point  should  be  cut  off  and  the  end  rounded,  to  avoid 
pricking  the  gingivae. 

In  connection  with  the  use  of  the  toothpick,  one  thing  should 
be  particularly  remembered;  that  decays  of  proximal  surfaces 
occur  only  when  the  gingivae  have  receded,  and  that  the  repeated 
forcing  of  a  toothpick  between  the  teeth  is  very  liable  to  cause 
the  gingivae  to  recede  more  and  therefore  may,  in  the  long  run, 
do  more  harm  than  good.  Only  those  whose  gums  have  already 
receded  sufficiently  to  give  room  for  a  toothpick  to  be  passed 
between  the  teeth  without  pressure  on  the  gum,  can  use  tooth- 
picks without  danger  of  causing  further  recession.  (See  Fig- 
ures 209  and  210.)  Few  persons  have  this  much  recession  before 
middle  age ;  it  is  for  this  reason  that  younger  persons  should  be 
very  careful  in  the  use  of  the  toothpick. 

Formerly  I  had  been  much  opposed  to  the  use  of  the  wooden 
toothpick,  because  of  more  or  less  slivering  of  the  wood  in  cut- 
ting them.  In  more  recent  years,  however,  many  manufacturers 
have  so  improved  the  product  as  to  eliminate  the  danger  of 
injury  to  the  gums  from  the  slivers.  One  should,  however, 
choose  wood  toothpicks  very  carefully,  and  buy  only  such  as  are 
smooth  —  actually  polished  all  over  —  and  free  from  slivers. 
There  are  still  plenty  of  the  cheaper  sort  to  be  avoided.  It  seems 
that  every  means  yet  devised  for  cleaning  the  proximal  surfaces 
of  the  teeth  must  be  used  with  care,  lest  the  gingivae  be  injured. 
A  toothpick  habit  is  liable  to  be  formed  in  which  the  person  will 
carry  a  wood  toothpick  sticking  between  certain  teeth.  This 
can  not  be  continued  long  without  seriously  injuring  the  septal 
tissue. 

RuBBEK  BANDS  AND  SILK  FLOSS.  Rubbcr  bauds  or  waxed  floss 
silk  are  generally  preferable  to  toothpicks  for  cleansing  the 
spaces  between  the  teeth.  Neither  should  be  used,  except  in 
those  spaces  where  there  has  been  slight  recession  of  the  gingivae, 
or  in  spaces  in  which  food  may  be  caught  occasionally,  even 
though  the  gingivae  are  normal.  Certain  foods,  such  as  chicken 
and  other  string}'"  meats,  are  much  more  likely  than  others  to 
slip  past  good  contacts,  or  to  slip  into  the  septal  space  from  the 
buccal,  labial  or  lingual.  A  silk  floss  or  a  rubber  band  is  usually 
necessary  to  remove  such  lodgments.  It  would  not  be  a  good 
plan  for  every  person  to  pass  a  rubber  band  or  floss  silk  between 
the  teeth  after  each  meal,  because  of  the  danger  of  irritating  the 
gingivae  and  causing  them  to  recede. 

In  using  either  the  rubber  band  or  floss  silk,  it  should  be 
held  with  the  fingers  close  up  to  the  teeth  on  either  side  and  then 


Fig.  487. 


Fig.  488. 


FlG.S.  487,  488.  "  Youtli's  "  sizo  and  "adult's"  size  hnislios  in  jjoskiou  on  tlio 
lower  molars.  It  will  be  observed  tiiat  the  smaller  brush  is  better  suited,  as  it  may 
be  more  easily  manipulated  in  the  mouth.     The  illustrations  are  actual  size. 


Fig.  489. 


Fig.  490. 


Figs  489,  490.  These  two  illustrations  show  the  position  of  the  brush  for  the 
lingual  surfaces  of  the  lower  bicuspids  an.l  molars.  While  the  brush  must  be  held 
diagonally  to  the  line  of  the  arch,  the  movement  should  be  the  same  as  on  the 
buccal  side.  TV.e  brush  should  be  placed  on  the  gum  and  shouM  then  be  swept 
occlusally  over  the  gingiva;  and  teeth. 


Fig.  491. 


Kid.     1!)L' 


Figs.  491,  492.  In  l)nishiii^^  tu  tlif  liiiciual  of  tlic  IdW.T  incisors,  the  brush  shouM 
be  hehl  paralli'l  to  the  long  axis  of  tiicsc  leetli.  Many  |..M,|.le  fail  to  brush  the  gums 
and  gingival  portions  of  the  teeth  in  tliis  position.  If  t  hr  lirusli  lias  a  handle  bent 
as  in  Figure  492,  the  end  bristles  will  toueh  the  gum  without  tlie  mouth  being 
opened  as  wide  as  would  be  required  with  the  brush  in  Figure  491. 
is  especially   neeess-irv   if  the  lower  in<'isors  ar(>  indinecl    linguaUy. 


bent    handle 


Fig.  493. 


Fig.  494. 


Figs.  493,  494.  A  "  youth's  "  size  brush  to  the  buccal  of  the  uj)per  molars.  In 
Figure  493  the  ramus  in  section  is  shown  in  its  position  in  many  mouths  when  the 
mouth  is  open,  preventing  the  luusii  from  reaching  the  third  molar.  In  Figure  494 
the  ramus  is  shown  in  its  position  wlien  the  mouth  is  closed,  giving  additional  room 
for  the  brush. 


MOUTH    HYGIENE.  433 

carried  very  slowly  past  the  contact  point.  In  doing  this  the 
ends  should  be  drawn  a  little,  either  to  the  mesial  or  distal,  so 
that  the  silk  or  the  band  will  pass  to  one  side  or  the  other  of  the 
crest  of  the  septal  gingiva  as  it  passes  the  contact,  thus  avoid- 
ing injury  to  this  tissue.  After  it  is  in  the  space  between  the 
teeth,  the  two  ends  should  be  drawn  back  and  forth  to  rub  the 
surface  of  one  tooth,  then  it  should  be  lifted  over  the  crest  of 
the  gingiva  and  the  surface  of  the  other  tooth  rubbed  in  a 
similar  way.  It  is  quite  a  task  to  do  this  carefully  and  thor- 
oughly in  each  of  the  thirty  spaces  between  the  teeth  and  few  of 
those  people  whose  teeth  need  such  cleaning  will  do  so  regu- 
larly. It  is,  however,  about  the  only  effective  method  of  clean- 
ing these  surfaces.  Patients  should  be  very  carefully  instructed 
in  the  manner  of  using  the  floss  or  rubber  band,  and  should  be 
impressed  with  the  danger  of  injury  to  the  soft  tissues. 

All  interproximal  spaces  which  require  the  use  of  a  tooth- 
pick, rubber  band  or  silk  floss  to  remove  food  debris,  should  be 
carefully  examined  to  determine  the  condition  of  the  contact. 
In  the  majority  of  cases,  unless  the  attachment  of  the  peridental 
membrane  has  been  seriously  injured,  it  should  be  possible  to 
correct  either  the  form  of  the  contact  or  the  tightness  of  it,  so 
that  food  will  not  be  caught.  The  methods  of  so  doing  have 
been  given  elsewhere. 

The  syringe.  It  is  often  hard  for  me  to  say,  when  consider- 
ing a  case  in  practice,  which  is  the  more  important  for  the  patient 
to  use,  the  brush  or  the  water  syringe.  But  there  is  no  such 
thing  as  dispensing  with  the  brush.  The  syringe  should  follow 
the  use  of  the  brush  and  the  toothpick,  or  the  rubber  band,  or  the 
silk  floss,  whichever  of  the  latter  three  may  be  employed.  The 
syringe  should  be  the  last  used.  There  are  three  principal  uses 
for  the  syringe,  (1)  to  maintain  the  health  of  the  gingivje  by 
cleansing  all  of  the  subgingival  spaces  —  the  proximal  subgingi- 
val spaces  as  well  as  those  on  the  buccal,  labial  and  lingual  ; 
(2)  to  remove  food  debris  from  interproximal  spaces;  (3)  to 
cleanse  pockets  which  may  have  occurred  alongside  the  roots,  as 
a  result  of  detachment  of  the  peridental  membrane  from  tlie 
cementum.  Food  debris  is  not,  as  a  rule,  forced  into  the  sub- 
gingival spaces,  except  occasionally  on  proximal  surfaces.  The 
object  of  washing  out  all  of  the  subgingival  spaces,  while  the 
gingivae  are  in  normal  or  nearly  normal  condition,  is  to  thor- 
oughly cleanse  them  by  removing  whatever  residue  may  remain 
from  the  serum,  often  containing  calco-globulin,  wliich  is  con- 
stantly discharged  into  these  spaces  from  that  portion  of  the 


434  SPECIAL   DENTAL    PATHOLOGY. 

gingiva^  which  overlies  the  enamel.  There  appears  to  be  little 
residue  in  these  spaces  during  childhood  and  early  adult  life, 
but  as  age  advances,  the  content  of  this  discharge  is  increasingly 
injurious,  and  the  indication  for  washing  the  spaces  is  corre- 
spondingly increased. 

For  removing  food  debris  from  the  interproximal  spaces, 
the  syringe  is  very  efficient,  and  is  especially  indicated  in  those 
mouths  in  which  there  has  been  a  recession  of  the  septal  gingivae, 
while  the  contacts  remain  tight.  In  such  cases  the  lodgments 
enter  the  spaces  from  the  buccal  or  lingual  and  are  not  packed 
in,  as  is  often  the  case  when  there  is  an  open  contact.  This 
condition  presents  most  frequently  in  the  mouths  of  persons 
past  middle  age.  The  syringe  is  also  of  service  in  removing 
debris  which  has  been  forced  past  weak  contacts,  or  crowded  in 
where  contacts  are  open. 

Whenever  detachments  of  the  peridental  membrane  have 
occurred,  the  syringe  offers  the  only  means  as  yet  suggested  by 
which  patients  may  clean  these  pockets  and  thereby  keep  the 
overlying  soft  tissue  in  the  best  possible  condition.  By  frequent 
irrigation  the  inflammation  may  be  controlled  and  the  resultant 
outpouring  of  serum  reduced  to  the  minimum.  The  stream  of 
water  should  be  thrown  with  full  power  of  the  hand  in  com- 
pressing the  bulb.  There  is  no  danger  of  using  such  force  as 
will  do  injury. 

The  syringe  should  have  as  large  a  rubber  bull)  as  can  be 
conveniently  held  in  the  hand.  The  nozzle  should  be  long  enough 
so  that  the  end  will  easily  reach  the  third  molars,  and  the  opening 
in  the  end  should  be  large  enough  to  give  a  good  strong  stream. 
The  bulb  of  the  syringe  shown  in  Figure  498  holds  one  and  one- 
half  ounces,  the  nozzle  is  three  inches  long,  and  the  diameter  of 
the  opening  in  the  end  is  1.5  mm.  Figure  187  shows  one  of 
these  syringes,  actual  size.  Aside  from  the  need  of  having  a 
large  opening,  it  is  important  that  the  end  of  the  nozzle  be  so 
large  that  it  would  be  impossible  to  get  it  under  the  free  margin 
of  the  gingiva^..  In  addition  to  its  effectiveness  in  cleaning,  a 
very  important  advantage  of  the  syringe  is  that  there  is  no 
danger  of  injury  to  the  gingiva?  in  its  use.  There  is  no  other 
method  of  doing  this  cleaning  which  does  not  present  consid- 
erable danger  from  frequent  slight  irritations.  These  have  been 
pointed  out  in  the  consideration  of  the  toothpick,  silk  floss  and 
rubber  band. 

In  using  the  syringe  one  should  follow  the  same  routine  as 
with  the  brush,  beginning,  we  will  say,  with  the  buccal  surface 


MOUTH    HYGIENE.  435 

of  the  lower  left  third  molar.  The  bulb  should  be  pressed  with 
full  force,  and  the  end  of  the  nozzle  should  be  drawn  over  the 
buccal  surface  of  the  tooth,  halting  slightly  in  the  forward  move- 
ment as  the  nozzle  comes  between  the  third  and  second  molars, 
then  over  the  second  molar,  halting  again  between  the  second 
and  first  molars,  and  continue  this  to  the  median  line.  With  a 
little  practice,  one  may  gauge  the  movement  so  that  this  will  use 
one  syringeful  of  water.  With  a  second  syringeful,  the  nozzle 
should  be  placed  on  the  buccal  surface  of  the  lower  right  third 
molar  and  drawn  forward  in  a  similar  way.  The  buccal  and 
labial  surfaces  of  the  upper  teeth  should  be  gone  over  in  the 
same  way;  then  the  lingual  surfaces  of  both  the  lower  and 
upper  teeth.  This  requires  eight  syringefuls  of  water.  If  one 
has  two  syringes,  only  about  one-half  the  time  will  be  necessary, 
for  there  need  be  no  waiting  for  the  bulb  to  fill  with  water.  One 
will  fill  while  the  other  is  being  used. 

The  nozzle  of  the  syringe  should  continuously  touch  the 
teeth,  and  be  so  inclined  as  to  force  the  water  toward  the  gingi- 
vae. (See  Figure  498.)  One  edge  of  the  nozzle  should  be  close 
to  or  barely  in  contact  with  the  margin  of  the  gingivae,  but  in  no 
case  should  the  effort  be  made  to  place  the  end  of  the  nozzle 
under  the  free  margin  of  the  gingivae,  on  account  of  the  danger 
of  injury  to  this  tissue.  The  tongue  and  lips  may  be  of  assis- 
tance in  guiding  the  end  of  the  nozzle  to  the  right  positions.  On 
the  lingual  side  of  the  arch  especially,  the  tip  of  the  tongue  will, 
after  some  practice,  guide  the  end  of  the  nozzle  as  it  is  passed 
around  the  arch,  and  thus  facilitate  the  movement. 

In  using  the  syringe  in  this  way,  all  parts  of  the  teeth  and 
all  of  the  subgingival  spaces  will  be  washed.  The  water  will 
generally  find  its  way  to  the  deepest  parts  of  the  septal  subgingi- 
val spaces  as  well.  Most  patients  will  soon  come  to  feel  the 
lifting  of  the  gingivae  as  the  water  enters  the  subgingival  s])aces. 
This  use  of  the  syringe  gives  a  sense  of  cleanness  and  comfort 
not  obtainable  in  any  other  way.  It  is  well  worth  the  effort 
expended  for  this  purpose  alone,  and  persons  who  once  learn 
this  use  of  the  syringe  will  gladly  continue  with  it  indefinitely. 
But  in  addition  to  this,  it  is  really  the  best  aid  to  the  brush  as  a 
cleaning  agent  which  we  have. 

The  sj^ringe  should  be  used  by  all  adults  and  young  adults 
as  a  part  of  the  regular  routine  cleaning  of  their  mouths.  This 
may  be  done  with  perfect  freedom  without  injuring  the  soft 
tissues.  As  a  rule  young  children  are  free  from  inflammations 
of  the  gingiva*,  other  than   those  caused  by   ])ro.\imal   decays 


436  SPECIAL    DENTAL    PATHOLOGY. 

which  permit  impactions  of  food,  or  other  causes  which  may  be 
definitely  and  promptly  remedied.  It  is  not  therefore  necessary 
that  young  children  use  the  syringe.  The  use  of  the  syringe 
should  be  begun  as  soon  as  there  is  apparent  the  danger  of  begin- 
ning proximal  decays. 

It  should  be  recognized  that  certain  impactions  of  food  will 
be  held  so  tightly  between  the  teeth  that  they  can  not  be 
removed  by  the  syringe  and  water  alone.  The  dentist  should  be 
able  to  so  modify  the  forms  of  proximal  surfaces  that  practically 
all  such  impactions  will  be  avoided. 

When  gingivce  are  i7iflanied.  If  the  gingivae  are  sore  and 
inflamed,  as  they  will  be  after  the  removal  of  deposits  of  calculus, 
physiological  salt  solution  should  be  used  in  the  syringe  instead 
of  plain  water,  until  all  soreness  is  passed.  Indeed,  whenever 
there  is  an  inflammation  or  a  break  in  the  tissues,  the  salt  solu- 
tion should  be  used,  and  the  washing  should  be  done  in  the  most 
thorough  manner.  Such  places  in  the  mouth  heal  particularly 
well  under  this  treatment.  No  antiseptics  of  any  kind  should 
be  used. 

In  cases  in  which  there  are  several  or  many  pockets,  physio- 
logical salt  solution  should  be  regularly  used.  Patients  should 
be  given  detailed  instructions  as  to  the  most  practical  and  conve- 
nient methods  for  carrying  out  this  work.  Probably  the  most 
satisfactory  plan  will  be  for  the  patient  to  have  a  bottle  of  salt 
tablets  and  a  glass  which  will  hold  eight  ounces.  The  glass  may 
be  filled  with  warm  water,  and  two  salt  tablets  added,  which  will 
make  the  proper  solution.    (See  Figure  177.) 

It  is  necessary  to  suggest  some  such  plan,  for  we  can  not 
expect  many  persons  to  do  this  washing  twice  daily,  month  after 
month,  and  year  after  year,  unless  it  may  be  done  with  little 
inconvenience  and  without  requiring  too  much  time.  As  has 
been  mentioned,  the  time  may  be  materially  reduced  by  having 
two  syringes,  one  of  which  will  be  filling  while  the  other  is 
being  used. 

MoUTH-WASHES,  PASTES  AND   POWDERS. 

No  mention  has  been  made  of  mouth-washes,  tooth-pastes, 
tooth-powders,  etc.  It  is  believed  that  these  are  of  very  little 
or  no  value  ;  that  everything  can  be  accomplished  with  plain  water 
and  a  brush  and  nothing  is  gained  by  the  use  of  medicine.  If 
there  is  no  disease  of  the  tissues  of  the  mouth,  certainly  no  medi- 
cine is  indicated.  If  the  mouth  is  thoroughly  cleaned  the  sense 
of  comfort  will  not  be  bettered  by  the  pleasant  taste  of  a  mouth- 


MOUTH    HYGIENE.  437 

wash.  There  is  no  merit  in  the  use  of  an  antiseptic  mouth-wash, 
as  its  effect  is  of  but  a  few  minutes  duration.  With  the  devel- 
opment of  more  complete  knowledge  of  the  etiology  of  dental 
caries,  we  have  come  to  realize  that  the  acidity  of  the  saliva  has 
nothing  to  do  with  decay  and  alkaline  mouth-washes  are  not 
indicated  to  prevent  decay.  No  solution  taken  into  the  mouth 
will  have  more  than  a  very  temporary  effect  and  will  be  of  no 
practical  value. 

Some  children,  and  possibly  a  limited  number  of  adults,  may 
be  induced  to  take  better  care  of  their  mouths  if  a  pleasant- 
tasting  mouth-wash,  or  powder,  or  paste  is  prescribed.  The  idea 
has  become  so  fixed  in  the  minds  of  our  people,  as  a  result  of 
advertising  propaganda  by  manufacturers  and  the  belief  of  many 
dentists  that  these  preparations  are  beneficial,  that  it  is  not  to 
be  expected  that  the  public,  or  the  members  of  the  profession, 
will  quickly  change  their  attitude,  but  in  the  light  of  our  present 
knowledge,  there  should  be  a  gradual  change  to  a  more  rational 
view.  In  the  meantime,  members  of  the  profession  should  thor- 
oughly familiarize  themselves  with  these  problems,  and  exer- 
cise judgment  in  presenting  the  facts  to  their  patients.  The  most 
that  can  be  said  for  the  majority  of  such  preparations  is  that 
they  are  probably  harmless,  although  there  can  be  little  doubt 
but  that  some  are  injurious.  If  it  is  believed  that  a  patient,  and 
particularly  a  child,  will  take  better  care  of  his  mouth  if  a 
pleasant-tasting,  harmless  preparation  is  used,  I  would  offer  no 
objection. 

Dentist  should  put  mouth  in  condition. 

It  should  be  the  first  duty  of  the  dentist  to  put  the  mouth  in 
condition.  If  there  are  deposits  of  either  salivary  or  serumal 
calculus,  they  should  be  removed;  places  where  food  lodges  on 
account  of  decays,  open  contacts,  imperfect  previous  operations, 
etc.,  should  be  corrected,  and  sensitive  teeth  should  be  cared  for. 
Then  the  training  of  the  patient  in  the  care  of  the  mouth  should 
begin.  The  mouth  should  be  put  in  the  best  possible  condition 
for  the  vigorous  use  of  the  teeth  and  should  be  as  free  from 
inflammations  as  possible,  so  that  thorough  brusliing  will  not 
cause  pain,  before  systematic  cleaning  by  the  patient  may  be 
undertaken  with  hope  of  success. 

I  have  frequently  seen  persons  who  have  tried  to  use  the 
brush  over  inflamed,  sore  and  bleeding  gingiva*,  only  to  make  an 
utter  failure,  because  the  tissues  were  too  sensitive  to  be  brushed. 
They  did  not  appreciate  the  conditions  which  rendered  the  brush 

40 


438  SPECIAL    DENTAL   PATHOLOGY. 

ineffective.  Often  several  days  are  required  after  scaling  opera- 
tions for  tlie  inflammation  of  the  gingivae  to  subside,  and  patients 
should  be  instructed  not  to  use  the  brush  during  this  time.  As 
has  been  mentioned,  the  dentist  should  have  such  cases  under  his 
observation  and  care  until  the  inflammation  has  subsided. 

When  cleaning  should  be  done. 

The  teeth  should  be  cleaned  after  each  meal.  To  this  rule 
there  should  be  no  exceptions.  It  is  the  only  safe  rule  for  the 
large  majority  of  persons  to  follow.  When  followed  in  this  way 
and  carefully  done,  it  insures  a  continuously  healthy  mouth,  so 
far  as  deposits  of  salivary  calculus  and  food  debris  are  con- 
cerned. There  is  a  special  virtue  in  cleaning  immediately  after 
meals.  To  one  who  has  formed  that  habit,  the  condition  of  the 
mouth  annoys  until  the  cleaning  is  done ;  it  can  not  be  forgotten. 

Some  people  may  neglect  the  care  of  their  mouths  for  years 
before  injury  will  result,  but  it  will  come,  sooner  or  later,  to  a 
large  percentage  of  such  persons.  It  should  be  remembered 
that  calculus  is  always  deposited  in  a  very  soft  form,  and  at 
once  begins  slowly  to  harden.  At  first  it  is  easily  brushed  away, 
but  if  neglected  for  a  day  or  two,  it  becomes  too  hard  for  this 
mode  of  removal.  Cleaning  at  stated  times  is  the  one  effective 
means  of  preserving  a  healthy  mouth.  It  is  within  the  reach 
of  every  person  who  becomes  sufficiently  interested  to  learn  how, 
and  will  do  it  faithfully.  Neglect  for  two  days  may  bring  con- 
ditions which  will  make  the  cleaning  ineffective  in  certain  posi- 
tions, because  of  the  hardening  of  lodgments. 

Because  of  the  effectiveness  of  regular  and  thorough  clean- 
ing, one  must  not  conclude  that  the  services  of  the  dentist  can  be 
dispensed  with.  Nearly  every  person  will  fail  in  some  part  of  the 
prescribed  routine.  They  may,  in  the  slow  changes  of  their  habits 
in  cleaning  the  mouth,  skip  some  essential  place.  The  dentist 
should  impress  the  importance  of  being  regularly  consulted,  in 
order  that  such  errors  may  be  corrected.  He  should  be  ever 
watchful  for  opportunities  to  criticize,  to  the  end  that  as  many 
patients  as  possible  may  be  gradually  trained  to  clean  their 
mouths  with  absolute  thoroughness.  Areas  which  are  apparently 
not  well  cleaned  should  be  pointed  out  and  the  habit  of  cleaning 
corrected.  This  service  on  the  part  of  the  dentist  should  never 
be  regarded  as  trivial  because  it  is  in  tlie  form  of  advice ;  on  the 
other  hand,  it  should  be  reckoned  as  one  of  the  most  helpful  ser- 
vices he  can  render. 


MOUTH    HYGIENE.  439 

Training  in  cleaning  of  the  mouth.  Every  person,  in 
forming  habits  of  cleaning  the  mouth,  should  be  under  the  direct 
supervision  of  the  dentist.  It  is  very  necessary  that  the  idea 
of  habit  be  recognized  in  anything  that  is  to  be  repeated  over 
and  over  again  in  the  same  way.  Correct  habits  in  every  par- 
ticular are  essential  in  this  cleaning.  In  the  formation  of  the 
habit,  every  part  of  the  mouth  which  needs  it  should  be  properly 
cleaned. 

No  other  person  than  the  dentist  should  be  regarded  as  fully 
competent  to  do  this  training,  because  no  other  person  has  the 
knowledge  and  skill  in  examination  which  renders  him  fit  to 
determine  whether  or  not  the  cleaning  is  in  every  way  efficient. 
For  this  reason,  patients  who  are  not  doing  effective  cleaning 
should  be  requested  to  bring  their  brushes  to  the  dentist's  office, 
in  order  that  their  use  of  them  may  be  criticized. 

As  an  example,  I  will  report  a  case  of  a  young  lady  who 
was  anxious  to  clean  her  mouth  properly.  She  had  learned  to 
use  the  brush  with  the  correct  motions,  but  in  examining  her 
mouth,  I  discovered  that  the  labial  surfaces  of  the  left  cuspids, 
both  upper  and  lower,  were  not  well  cleaned.  Each  had  a  growth 
of  micro-organisms  about  the  crest  of  the  gingivae.  If  this  had 
been  on  the  right  side,  I  should  have  known  the  cause  at  once. 
After  a  moment's  thought,  I  asked  the  young  lady  if  she  was 
left-handed.  She  looked  at  me  curiously,  and  said,  ''Why  do 
you  ask  such  a  question?"  I  gave  her  a  hand  mirror  and 
pointed  out  the  areas  which  had  not  been  brushed,  and  said, 
"You  must  have  used  your  left  hand  and  did  not  quite  make 
ends  meet."  That  is,  beginning  with  the  molar  teeth  on  the 
right  side  of  the  mouth,  she  would  carry  the  brushing  around 
to  the  left  lateral  incisors ;  and  then  beginning  on  the  left  side 
she  would  brush  the  molars  and  bicuspids ;  the  left  cuspids 
were  not  brushed.  This  is  an  example  of  the  errors  which  occur 
in  the  habits  of  cleaning  the  teeth.  With  the  person  who  holds 
the  brush  with  the  right  hand  this  failure  would  be  on  the  right 
side  of  the  mouth  instead  of  the  left.  This  patient  acknowledged 
that  she  was  left-handed,  and  declared  that  she  would  make 
"ends  meet"  in  the  future.  It  is  only  by  this  careful  plan  of 
examination  and  direction  that  we  can  bring  some  people,  who 
are  conscientious  in  their  efforts,  to  be  really  thorough. 

I  will  relate  another  case  which  I  think  will  be  of  interest, 
particularly  because  it  was  the  first  serious  case  of  disease  of 
the  peridental  membrajie  which  I  treated  absolutely  without 
antiseptics. 


440  SPECIAL   DENTAL   PATHOLOGY. 

A  young  lady  came  to  see  what  I  could  do  for  her  mouth, 
having  been  recommended  to  me  by  one  of  my  very  good 
patients.  I  found  her  mouth  much  inflamed  from  deposits  of 
salivary  calculus.  I  told  her  that  I  would  not  undertake  the 
treatment  of  her  case  unless  she  was  willing  to  follow  my  advice 
in  every  detail  as  to  the  future  care  of  her  mouth.  To  this  she 
assented,  after  questioning  me  as  to  what  I  would  require.  She 
promised  full  consent  and  obedience,  except  to  the  extraction 
of  a  left  lower  third  molar  that  was  then  very  loose,  on  account 
of  detachments  of  the  peridental  membrane.  I  told  her  that  I 
would  risk  getting  that  out  of  the  way.  Her  case  was  appar- 
ently one  of  long  standing,  though  she  claimed  it  was  not,  and 
I  undertook  the  treatment  with  some  misgivings  as  to  the  result. 
She  proved  to  be  an  excellent  patient. 

After  the  removal  of  the  calculus,  I  found  the  injury  about 
individual  teeth  very  unequal.  In  some,  a  part  of  the  bony 
alveolar  process  was  gone.  In  others  the  full  bony  process 
was  standing.  I  determined  to  cut  away  the  tissues  from  all 
of  the  teeth  to  nearly  the  depth  of  the  worst  injuries,  of  which 
there  were  a  number  much  alike,  in  order  that  a  new  line  of 
attachment  of  the  gingiv;e  might  be  formed  as  nearly  regular 
as  possible,  to  facilitate  cleaning.  I  thought  that  the  crest  of 
the  new  gingivae  might  finally  be  about  the  height  of  the  gin- 
gival line,  grading  to  a  somewhat  lower  level  for  a  part. 

After  this  operation,  the  tissues  healed  well.  All  pus  for- 
mation was  carried  away  at  a  dash,  except  about  the  very  loose 
third  molar,  which  she  would  not  permit  me  to  extract.  To 
undertake  the  treatment  of  it  by  uncovering  the  suppurating 
areas  would  almost  accomplish  its  removal,  and  especially  on 
the  buccal  side,  would  involve  the  removal  of  more  tissue,  much 
of  it  hard  bone,  than  I  felt  justified  in  doing  for  a  tooth  that 
would  apparently  fall  away  in  a  few  months.  The  new  line  of 
gingivcTB  seemed  well  established,  and  was  very  satisfactory. 
After  I  had  had  the  case  under  observation  for  several  months, 
this  patient  was  ordered  to  Europe  to  do  certain  work  to  which 
she  was  assigned,  and  did  not  return  until  the  end  of  fifteen 
months.  She  then  came  to  see  me.  I  asked  her  when  she  had 
the  loose  tooth  out,  and  she  replied:  "Don't  ask  me  any  ques- 
tions until  you  have  examined  my  mouth." 

The  next  day  I  found  the  third  molar  standing  in  the  row 
hard  and  fast,  with  less  than  one-third  of  the  root  in  the  tis- 
sues. She  evidently  could  use  this  tooth  in  mastication  much 
the  same  as  the  others,  as  she  claimed.    The  tissue  that  I  had 


Fig.  495. 


Fig.  4!)(;. 


Fig.  49~).  Tlu'  l)riisli  is  sliowii  iii  tlic  indiicr  position  on  the  yum  for  tlu'  motion 
downward   in   brusliing   the   upjuT   front   teeth. 

Fig.  496.  A  little  briisli  with  a  tuft  of  bristl(>s  on  the  end  is  desir:ibh>  in  many 
montlis  to  elean  tlie  hueeal  and  distal  surfaces  of  third  molars  hv  reaching  over  the 
occlusal  surface.  This  is  a  brush  desi;jiied  by  Dr.  .lulos  .1.  Sarrazin,  of  New 
Orleans,  Louisiana. 


*40 


Fig.  497. 


Fig.  497.  A  brush  with  the  long  tuft  of  bristles  on  the  end  showing  how  this 
tuft  prevents  the  shorter  near-by  bristles  from  touching  the  teeth,  also  how  the  long 
bristles  fold  back  in  positions  where  there  is  not  ample  room. 


MOUTH    HYGIENE,  441 

refused  to  cut  away  had  been  removed  by  absorption.  The  new 
line  of  gingiva'  was  hard  and  firm  in  every  part,  and  smootli 
enough  to  be  easily  cleanable. 

Clearly  my  patient  had  the  best  of  me,  or  to  put  it  differ- 
ently, she  succeeded  in  retaining  the  tooth  in  spite  of  me.  She 
said  that  in  the  fifteen  months  that  she  had  been  away  she  had 
not  missed  the  full  cleaning  process  three  times  per  day,  and 
that  the  third  molar  always  had  two  extra  syringefuls  of  water. 
She  was  delighted  with  the  result. 

The  gingiva?  were  very  short.  The  whole  circle  of  the  gin- 
gival line  could  be  seen  upon  many  of  the  teeth,  and  some  part 
of  it  on  all  of  them.  As  had  been  noted  at  first,  the  lips  covered 
the  teeth  so  well  that  the  loss  of  the  gingivae  was  not  noticeable. 
Her  teeth  made  an  excellent  showing,  both  in  talking  and  in 
laughing.  Her  bite  was  strong  enough  to  manage  a  beefsteak 
or  other  of  the  ordinary  foods. 

Artificial  cleaning  unnecessary  for  some  persons.  There 
is  much  variation  in  the  requirements  in  artificial  cleaning 
among  different  people.  Some  persons  under  forty  years  need 
no  artificial  cleaning.  I  have  examined  a  few  such  persons 
^vithin  an  hour  after  a  meal,  and  although  a  tooth-brush  had 
not  been  used,  their  mouths  were  as  clean  as  those  of  the  most 
careful  and  fastidious  patients.  It  seemed  that  debris  which 
remained  after  meals  was  dissolved  —  digested  by  their  saliva 
—  and  removed  completely  in  a  short  time. 

One  rather  notable  person  whom  I  frequently  had  under 
observation  during  the  latter  part  of  her  life,  had  never  owned 
a  tooth-brush.  It  was  her  continuous  habit  after  meals  to  take 
a  glass  of  water,  and  filling  her  mouth,  force  this  through  between 
and  among  the  teeth,  and  cast  it  out.  As  I  often  saw  her  do  this, 
she  used  up  the  full  glass  of  water  in  mouthful  after  mouthful, 
and  there  the  cleaning  ended.  She  never  had  a  decayed  tootli, 
she  never  had  a  crust  of  calculus,  and  at  seventy-six,  when  she 
died  of  pneumonia,  her  gingivtr  were  as  full  and  complete,  and 
rose  as  high  upon  the  crowns  of  the  teeth  as  was  normal  for  the 
girl  eighteen  years  of  age. 

A  few  patients  of  this  class  came  regularly  several  times 
a  year  for  examination.  If  more  of  those  people  who  need  but 
little  attention  would  do  this,  many  cases  of  disease  of  the  peri- 
dental membrane  would  be  prevented.  It  is  important  to  remem- 
ber that  persons  who  are  immune  to  caries  may  have  deposits 
of  calculus,  and  because  of  the  preexisting  sense  of  security 
which  the  normal  cleanliness  had  engendered,  it  will  l)e  dillicnit 

40b 


442  SPECIAL   DENTAL    PATHOLOGY. 

to  bring  them  to  take  sufficient  care  when  artificial  cleaning 
becomes  necessary.  These  are  usually  very  difficult  cases  to 
manage.  It  will  often  require  all  of  the  influence  that  can  be 
brought  to  bear,  to  make  them  realize  the  necessity  of  frequent 
and  thorough  brushing. 

Irregularities  of  the  GiNGiViE.  Scars  of  the  gingivae  result 
from  previous  injuries,  which  have  caused  changes  from  the 
normal  form.  These  require  extra  care  in  brushing,  which  must 
be  varied  to  meet  the  particular  case.  There  may  have  been  a 
shallow  pocket  formed  in  the  attachment  of  the  peridental  mem- 
brane of  a  certain  tooth.  This  may  have  recovered,  leaving  a 
notch  in  the  regular  line  of  the  crest  of  the  free  gingivae,  in  which 
debris  will  lodge  and  be  difficult  to  remove.  In  another  case, 
the  crest  of  the  gingivae  may  have  become  thickened,  forming  a 
shelf  w^iere  it  lies  against  the  tooth,  which  tends  to  the  collec- 
tion of  debris.  A  still  more  serious  condition  arises  from  the 
shortening  of  a  septum  here  and  there,  which  calls  for  special 
care  in  the  cleaning  of  these  interproximal  spaces.  In  old  age 
the  whole  of  the  free  gingivae  sometimes  become  short  and  much 
thickened  at  their  margins,  and  the  septal  gingivae  no  longer 
fill  the  spaces  between  the  teeth. 

All  such  injuries  tend  especially  to  increase  the  lodgment 
of  deposits,  both  of  food  debris  and  calculus,  and  in  this  way 
endanger  the  health  of  the  parts.  This  danger  occurs  mostly 
because  of  the  tendency  of  such  defects  to  cause  lodgments.  Most 
of  the  irregTilarities  of  position  of  the  teeth  present  their  own 
particular  difficulties  to  the  cleaning  process.  The  cleaning  must 
be  varied  to  meet  these  conditions.  If  the  gingivie  are  blunted, 
tliey  will  be  gradually  thinned  by  regular  brushing  with  ])roper 
motions. 

Cleaning  artificial  dentures. 

Artificial  dentures  or  bridges,  either  fixed  or  removable 
pieces,  should  receive  more  attention  in  the  matter  of  cleanli- 
ness than  the  natural  teeth.  This  is  necessary  to  the  full  and 
comfortable  use  of  such  appliances.  Neglect  is  sure  to  bring 
serious  inflammation  sooner  or  later. 

The  epithelium  of  the  mouth,  which  is  fitted  for  the  friction 
it  receives  in  chewing  food,  is  continually  giving  off  dead  cells 
fi-om  its  surface  and  renewing  them  by  fresh  growth.  If  a  por- 
tion of  this  mucous  meml)rane  is  constantly  covered  by  a  den- 
ture, which  fits  so  well  that  food  debris  does  not  get  under  it, 
the  dead  cells  will  remain  and  within  a  dav  or  so  will  cause  the 


MOUTH    HYGIENE.  443 

entire  surface  of  the  mucous  membrane  under  the  denture  to 
be  slightly  or  considerably  whitened.  If  these  dead  cells  are 
not  brushed  away,  they  will  soon  decompose  and  render  foul 
the  whole  surface  of  the  denture  in  contact  with  the  tissue.  It 
often  happens  that  more  or  less  food  debris  will  work  in  under 
some  dentures,  and  this  will  decompose,  causing  inflammation 
of  the  mucous  membrane.  It  is,  therefore,  a  necessity  to  the 
comfort  and  full  use  of  the  denture  that  the  cleaning  of  it  and 
the  mouth  be  done  at  regular  intervals,  the  same  as  the  cleaning 
of  the  natural  teeth. 

The  denture  should  be  placed  under  the  hot-water  faucet, 
if  running  water  can  be  used,  while  the  mouth  and  the  natural 
teeth,  if  some  remain  in  the  mouth,  are  cleaned.  The  mucous 
membrane,  over  which  the  plate  fits,  should  receive  a  very  thor- 
ough cleaning  with  a  brush  —  one  having  bristles  rather  softer 
than  those  used  for  cleaning  natural  teeth.  This  will  remove 
all  deposits  and  dead  epithelium  which  may  have  collected  under 
the  denture,  and  give  to  the  tissues  a  sense  of  comfort. 

The  denture  should  be  examined,  by  touching  it  here  and 
there  with  the  fingers.  It  will  soon  be  recognized  that  the  mucus, 
which  gave  it  a  slippery  feeling  when  it  was  removed  from  the 
mouth,  has  been  washed  away  by  the  water.  If  some  little  cal- 
culus has  collected  here  and  there,  this  will  remain  and  such 
spots  will  feel  greasy  to  the  fingers.  This  deposit  of  soft  calculus 
can  not  be  removed  by  running  water,  but  is  easily  removed  by 
vigorous  brushing.  For  this  purpose,  a  small  hand  brush,  with 
the  bristles  thickly  set,  should  be  used.  (See  Figure  500.)  Noth- 
ing besides  the  brush  and  water  is  needed  for  cleaning  the  plate, 
though  there  is  no  objection  to  using  a  little  soap.  The  brush- 
ing should  be  continued  until  the  plate  is  perfectly  clean  in  every 
part.  The  movements  of  the  brush  should  include  those  neces- 
sary to  bring  the  bristles  through  the  embrasures  between  the 
teeth  on  both  the  buccal  and  lingual  sides.  That  part  of  the 
palatal  surface  which  lies  next  to  the  tongue,  as  well  as  the  sur- 
face which  comes  in  contact  with  the  mucous  membrane,  should 
be  made  thoroughly  clean. 

Then  that  part  of  the  plate  which  covers  the  residual  alve- 
olar ridge  should  be  brushed  with  the  special  brush,  designed  for 
the  purpose,  and  care  should  be  taken  to  reach  every  part  of  this 
surface.  (See  Figure  499.)  It  is  not  sufficient  to  simply  place 
the  brush  in  the  groove  and  brush  around  the  groove.  The  angle 
at  which  the  brush  is  held  must  ])e  changed  so  that  every  part 
will  be  cleaned.    Some  regulai-  oi'der  sliould  be  followed  so  that 


444  SPECIAL,  dentatj  pathology. 

every  part  of  the  plate  will  receive  sufficient  brushing  to  render 
it  clean. 

If  there  is  calculus  coming  into  the  mouth,  more  or  less  of  it 
will  be  deposited  somewhere  on  the  plate,  and  if  the  cleaning  is 
neglected,  this  deposit  will  become  so  hard  that  it  can  not  be 
removed  by  the  brush.  Whereas  when  the  deposit  is  fresh,  hav- 
ing accumulated  between  meals  or  over  night,  as  the  longest 
period  between  cleaning,  it  will  be  so  soft  as  to  be  easily  removed 
by  brushing.  Therefore,  if  one  neglects  the  cleaning,  the  plate 
will  soon  be  in  such  condition  that  it  can  not  be  well  cleaned  with 
the  brush.  Then  it  will  cause  more  and  more  inflammation  of 
the  mucous  membrane  until  it  is  again  polished.  Persons  will 
soon  learn  that  the  deposits  of  calculus  occur  in  the  same  places 
time  after  time.  These  are  especially  the  buccal  surfaces  of 
upper  plates  about  the  molars  and  the  lingual  surfaces  of  lower 
plates  in  the  incisor  region. 

Neglect  of  cleaning  will  lessen  the  comfort  and  usefulness 
of  the  plate,  and  in  time  the  mucous  membranes,  over  which  it 
fits,  may  become  so  inflamed  that  it  can  not  be  used  with  the  vigor 
which  is  necessary  to  the  proper  chewing  of  food.  If  the  use  of 
a  foul  plate  is  persisted  in,  the  condition  of  the  mucous  mem- 
brane may  become  such  as  to  prevent  its  use  entirely,  or  render 
such  usage  very  uncomfortable  and  inefficient.  I  have  seen 
mouths  so  sore  that  the  plate  could  not  be  used  at  all  in  the  chew- 
ing of  food.  It  is  not  my  intention,  however,  to  go  into  the  con- 
sideration of  the  diseases  of  the  mucous  membrane  induced  in 
this  way. 

The  form  of  the  surface  next  to  the  lips  and  cheeks  should 
l)e  of  even  fulness,  and  the  embrasures  between  the  teeth  should 
be  filled  out  so  full  that  food  crushed  between  the  teeth  will  run 
through  them  with  such  force  as  to  tend  to  keep  them  clean. 
They  will  then  be  of  the  best  form  to  facilitate  cleaning  with  the 
brush.  There  should  be  no  irregularities  of  the  surface  in  any 
part  of  the  denture,  and  the  polish  should  be  as  perfect  as  it 
can  be  made.  This  matter  of  polish  is  of  great  importance  in 
preventing  the  catching  of  deposits  of  calculus  by  the  plate. 
Dentures  which  have  been  worn  for  some  time  will  receive  the 
first  deposits  in  low  places  upon  the  surface,  over  which  food 
will  pass  without  rubbing. 

The  dentist  should  study  this  point  with  the  greatest  care 
and  so  form  the  surface  of  the  plate  that  it  will  not  be  liable  to 
catch  and  hold  debris  of  any  kind  and  will  not  readily  catch  sali- 
vary calculus.    It  is  quite  possible  to  so  construct  and  polish  a 


Fig.  498. 


Fig.  498.  The  rubber  bulb  syringe  for  patients  to  use  in  washing  interproximal 
and  subgingival  spaces  The  nozzle  has  a  1.5  mm.  hole  in  the  end.  It  is  carried 
along  the  crests  of  the  gingiva?,  the  end  touching  the  enamel  close  to  the  gingiva?, 
while  held  at  such  an  angle  that  the  water  will  strike  the  enamel  and  be  directed  into 
the  subgingival  spaces.  This  is  a  very  efl'ective  means  of  keejiing  the  gingivae  in 
the  best  condition,  and  of  cleansing  the  interproximal  sjjaccs.  particularly  in  cases 
in  which  the  septal   gingiva'  have  receded  a    little. 


Fi(i.   499. 


Figs.  499,  500.  Hnishcs  for  iirtifici.-il  ilcnturcs.  actiral  size.  The  hnisli  shown  in 
Figure  499  is  desired  especialiy  fur  brushing;  the  part  of  the  plate  which  covers  the 
residual  alveolar  ridge.  For  plates  with  high  rims  the  tuft  on  end  must  be  enough 
longer  to  easily  reach  the  p(irti<iii  wiiich  covers  rlic  alveolar  ridge.  The  larger  brusli, 
Figure  500,  may  be  used  for  thr  vr^\  of  tlic  denture     This  is  a  small  hand  brush. 


MOUTH    HYGIENE.  445 

plate  as  to  avoid  any  calculus  whatever  from  adhering  to  it. 
Perhaps  it  is  not  possible  to  maintain  this  in  usage.  Its  mainte- 
nance will  require  repolishing  now  and  then,  but  this  can  be 
easily  done,  and  thus  keep  the  plate  in  a  condition  so  that  cal- 
culus will  not  adhere,  as  has  been  noted  in  the  articles  describing 
conditions  of  fresh  deposits  of  salivary  calculus. 

I  remember  well  one  patient,  the  case  occurring  a  number 
of  years  ago,  for  whom  I  had  extracted  all  of  the  teeth  when  she 
was  about  thirty  years  old,  on  account  of  disease  induced  by 
persistent  deposits  of  calculus,  and  had  made  artificial  dentures. 
I  requested  her  to  return  several  times  for  examination,  I 
instructed  her  carefully  in  the  matter  of  cleaning  both  her  mouth 
and  the  dentures,  and  she  seemed  to  fully  understand  what  she 
should  do.  I  heard  nothing  from  her  for  about  six  months,  when 
she  came  in  complaining  that  her  mouth  was  sore  under  the  plates 
and  that  the  plates  had  become  rough.  Upon  examination  I 
found  heavy  deposits  of  calculus  upon  them  and  the  mucous 
membranes  were  sore  wherever  the  dentures  fitted  against  them, 
as  would  naturally  be  the  case  from  the  condition  in  which  I 
found  the  dentures  as  to  cleanliness.  I  called  her  attention  to 
this  and  told  her  that  she  had  not  kept  the  plates  properly  cleaned. 
I  cleaned  and  polished  them  anew.  Then  I  sat  down  with  her 
and  talked  to  her  about  the  necessity  of  cleaning  artificial  teeth 
and  went  over  in  detail  the  whole  plan  of  cleaning  and  the  results 
that  were  likely  to  occur  if  my  directions  were  not  followed.  It 
was  evident  that  she  was  very  much  offended,  but  I  finished  what 
I  had  to  say.  She  went  away  without  a  word.  I  never  expected 
to  see  her  again.  About  six  months  after  that  she  came  in  and 
asked  me  to  examine  her  plates  and  her  mouth,  I  looked  them 
over  very  carefully  and  simply  said  ''excellent."  She  told  me 
that  the  principal  object  of  her  visit  was  to  thank  me  for  what 
I  had  done  for  her  when  she  last  visited  me. 

Cleaning  bridges. 

Persons  for  whom  fixed  bridges  have  been  placed  are  likely 
to  find  discomfort  in  the  lodgment  of  food  debris  about  such 
pieces,  unless  they  have  been  made  with  due  care  to  render  the 
cleaning  of  them  easy.  The  exposed  parts  of  such  pieces  may 
be  cleaned  by  the  ordinary  brush  used  in  cleaning  natural  teeth, 
but  that  portion  directed  toward  the  mucous  membrane  can  not 
be  well  cleaned  in  this  way,  and  other  means  should  be  devised 
by  the  dentist  for  the  particular  case.  No  part  of  a  bridge  should 
press  on  the  mucous  membrane ;  it  should  be  supported  wholly 


446  SPECIAL   DENTAL.   PATHOLOGY. 

by  its  abutments.  It  should  not  come  so  close  to  the  mucous 
membrane  but  that  a  piece  of  thin  tape  may  be  passed  between 
the  two  and  used  to  rub  over  the  part  of  the  appliance  that  can 
not  be  reached  by  the  brush.  For  this  to  be  effective,  the  sur- 
face of  the  dummies  toward  the  tissues  should  be  convex  from 
buccal  to  lingual,  rather  than  concave  as  many  are  made,  espe- 
cially in  the  portion  of  the  surface  toward  the  lingual.  This 
rubbing  by  a  simple  cotton  tape,  carrying  no  abrasive  whatever, 
followed  by  the  syringe,  will  complete  the  cleaning. 

If  the  cleaning  is  regularly  done  after  each  meal,  the  bridge 
should  be  kept  in  excellent  condition.  If  the  cleaning  is  not  regu- 
larly done,  inflammations  of  the  mucous  membrane  about  the 
bridge  and  under  it  are  very  likely  to  occur.  Furthermore  the 
soft  tissues  about  the  teeth  and  roots,  to  which  the  bridge  is 
attached,  are  liable  to  inflammation,  which  may  result  in  the 
loss  of  both  the  teeth  and  the  bridge.  These  difficulties  make  the 
continued  use  of  the  bridge  after  many  years  very  doubtful. 
Although  originally  constructed  so  as  to  facilitate  cleaning, 
changes  may  occur  to  render  the  cleaning  more  and  more  diffi- 
cult until  disease  is  induced  about  the  roots  supporting  the 
bridge. 

Bridges  require  more  care  than  any  other  of  the  artificial 
appliances  placed  in  the  mouth.  Similar  care  must  be  exercised 
in  the  construction  of  the  bridge ;  it  should  be  made  with  the 
utmost  precaution  that  every  part  be  thoroughly  cleanable  and 
present  sufficient  space  about  the  mucous  membranes  to  give  free 
access  to  the  natural  movements  of  the  fluids  of  the  mouth.  This 
and  the  continuous  cleaning  are  essential  to  the  best  results. 

Much  harm  is  being  done  by  bridges  which  are  neglected  or 
can  not  be  properly  cleaned.  They  become  a  menace  to  health 
by  the  inflammations  which  they  cause  and  become  harbors  for 
micro-organisms.  The  dentist  should,  whenever  a  bridge  is  set, 
instruct  the  patient  in  the  means  of  cleaning  it.  At  subsequent 
visits  he  should  note  whether  or  not  the  cleaning  is  being  done 
properly. 


EXAMINATIONS   OF   THE    MOUTH.  447 


EXAMINATIONS  OF  THE  MOUTH 

By  ARTHUR  D.  BLACK,  M.  D..  D.  D.  S. 
ILLUSTRATIONS:    FIGURES  501-507. 

THE  importance  of  very  painstaking  and  thorough  examina- 
tions of  the  mouth  has  been  emphasized  in  the  consideration 
of  each  subject  presented.  The  service  of  the  dentist  will 
increase  in  effectiveness  toward  prevention  as  he  learns  to  recog- 
nize the  beginnings  of  disease.  In  proportion  as  inflammations 
of  the  gingivae  are  recognized  and  treated  early,  will  cases  of 
chronic  suppurative  pericementitis  be  prevented;  likewise,  as 
decays  are  discovered  early,  will  cases  of  pulp  death  and  alveo- 
lar abscess  be  diminished.  No  elaboration  of  these  statements 
seems  necessary  to  one  who  has  read  this  book. 

The  subject  of  mouth  examinations  is  included  here  for  the 
purpose  of  presenting  a  systematic  plan  of  examining  and 
recording  all  conditions  which  should  be  noted.  The  record  of 
an  examination  is  of  almost  as  much  importance  as  the  exam- 
ination itself,  by  reason  of  the  fact  that  the  habit  of  record- 
ing necessitates  a  clear  mental  picture  of  the  condition  to  be 
recorded.  This  begets  keener  observation  and  develops  the 
faculty  of  logical  thought  and  proper  deductions,  as  applied  to 
the  conditions  presenting.  The  man  who  develops  the  habit  of 
making  accurate  records  will  soon  learn  to  see  as  much  more  in 
mouth  examinations  as  does  the  trained  microscopist  as  com- 
pared with  the  beginner.  The  record  will  often  be  found  of 
much  value  in  the  later  treatment  of  cases,  and  the  gradual 
accumulation  of  records  should  eventually  be  the  basis  of  tabu- 
lated reports  which  would  prove  to  be  the  best  guide  for  future 
practice. 

While  this  book  is  devoted  to  the  diseases  of  the  gingivae, 
peridental  membrane  and  dental  pulp,  these  conditions  are  so 
closely  related  to  other  procedures  that  it  seems  desirable  to 
present  a  plan  for  a  complete  mouth  examination.  This  plan 
is  one  which  has  been  followed  in  its  principal  features  by  the 
writer  for  fifteen  years.  When  once  understood,  its  application 
is  much  more  simple  than  the  rather  extended  description  of  the 
details  might  indicate.  Its  practicability  has  been  quite  thor- 
oughly tried  out  by  a  number  of  operators. 


448  SPECIAL   DENTAL    PATHOLOGY. 

Persons  who  apply  to  the  dentist  may  be  placed  in  three 
groups:  1.  Those  who  present  at  more  or  less  definite  inter- 
vals for  routine  examinations,  usually  without  any  particular 
complaint.  2.  Those  who  come  because  of  some  particular  con- 
dition of  pain  or  discomfort,  which  may  require  that  the  exam- 
ination be  directed  to  this  condition,  and  contraindicates  a 
complete  mouth  examination  at  the  time.  3,  Those  who  are 
suffering  from  some  secondary  infection  for  which  a  mouth 
focus  is  sought.  We  need  consider  only  the  routine  examination 
for  the  first  group,  as  it  will  include  the  conditions  presenting 
under  the  second  and  third  groups. 

As  a  part  of  every  examination  the  dentist  should  have  the 
best  possible  opinion  of  the  patient's  general  physical  condition. 
This  is  important,  not  only  in  connection  with  the  management 
of  regular  patients  who  come  for  routine  examinations  at  stated 
intervals,  but  also  for  those  who  may  present  for  the  first  time 
while  suffering,  or  who  may  be  referred  by  the  physician  on 
account  of  some  systemic  effect  of  a  local  focus.  While  it  is 
without  the  sphere  of  the  dentist  to  make  a  full  physical  exam- 
ination, he  may  by  such  observation  and  inquiry  as  the  circum- 
stances will  permit,  gain  much  information  which  will  be  of 
service.  When  there  are  mouth  infections  which  are  evidently 
of  long  standing,  and  particularly  if  the  patient  seems  not  to 
be  in  robust  health,  the  dentist  should  refer  the  patient  to  a 
physician  for  a  thorough  physical  examination.  The  patient's 
general  manner,  alertness  in  movements  and  conversation,  the 
color  of  the  skin,  the  facial  expression,  etc.,  will  usually  give  the 
dentist  sufficient  information  to  guide  him  in  the  conduct  of  his 
operations.  It  is  of  course  understood  that  the  pulse  and  tem- 
perature will  be  taken  in  all  cases  in  which  there  is  an  indication 
for  so  doing.  The  point  to  be  emphasized  here  is  that  the 
dentist  should  cultivate  his  powers  of  observation  to  enable  him 
to  determine  the  best  course  to  pursue  in  the  management  of 
patients,  in  order  that  his  service  may  be  most  effective. 

KOUTINE   MOUTH   EXAMINATION. 

A  complete  examination  of  both  the  soft  and  hard  tissues  of 
the  mouth  should  be  made  at  regular  intervals,  the  frequency  to 
be  determined  for  each  patient.  As  a  general  statement,  it 
might  be  said  that  for  the  majority  of  children  under  ten  years 
of  age,  the  examinations  should  be  every  three  months ;  for  most 


EXAMINATIONS    OF    THE    MOUTH.  449 

persons  from  ten  to  twenty  years  of  age,  three  times  or  twice  a 
year;  for  persons  past  twenty,  twice  a  year. 

Dentists  who  will  adopt  a  reliable  plan  for  notifying  patients, 
should  offer  to  take  the  responsibility  of  sending  notices  for  such 
examinations.  Unless  a  plan  is  followed  by  which  there  will  be 
little  likelihood  of  failure  to  send  notices  at  the  proper  times,  the 
responsibility  had  better  be  left  with  patients, 

A  good  plan  is  to  have  a  memorandum  column  in  the  regular 
appointment  book,  so  that,  as  a  series  of  operations  for  each 
patient  is  finished,  the  name  may  be  entered  in  this  column 
under  the  date  on  which  the  next  notice  for  examination  is  to  be 
sent.  There  is  little  opportunity  to  overlook  such  a  memoran- 
dum, as  it  will  be  seen  alongside  the  regular  appointments  when 
the  time  arrives.  This  plan  requires  that  the  book  for  the  next 
year  be  ready  six  months  or  more  in  advance,  or  one  may  set 
aside  a  few  pages  in  the  back  of  the  book  of  the  current  year  — 
one  for  each  month  —  and  make  the  entries  there,  subsequently 
transferring  them  to  the  proper  places  in  the  book  for  the  new 
year. 

A  card  system  may  be  used  for  this  purpose.  For  this,  one 
should  have  monthly  guide  cards,  and  the  cards  for  patients  who 
are  to  be  notified  may  be  placed  back  of  the  guide  for  the  month 
when  the  next  notice  is  to  be  sent.  The  same  guide  cards  and 
the  same  patients'  cards  may  be  used  indefinitely.  The  date 
should  be  entered  on  the  patient's  card  whenever  a  notice  is  sent. 
Under  either  plan  it  will  be  found  most  convenient  to  send  out 
all  of  the  notices  for  each  month  on  a  single  day,  or  possibly  on 
two  days  —  the  1st  and  the  15th. 

Some  patients  will  prefer  to  take  upon  themselves  the 
res])onsibility  of  their  return,  and  the  suggestion  that  the  dentist 
notify  them  will  not  be  acceptable.  The  dentist  should  there- 
fore do  no  more  than  to  otTer  to  make  a  memorandum  and  send 
such  a  notice  if  the  patient  desires  him  to  do  so.  When  notices 
are  sent  it  is  well  to  state  that  the  patient  may  cancel  the 
appointment  if  the  time  set  is  not  convenient.  The  patient 
should  be  impressed  with  the  fact  that  the  arrangement  is  made 
primarily  for  the  best  care  of  his  mouth,  and  not  as  an  economic 
procedure  for  the  benefit  of  the  dentist. 

In  making  a  routine  examination  the  dentist  should  have 
in  mind  the  following  conditions: 

1.  The  occlusion. 

2.  General  condition  of  the  teeth, 

41 


450  SPECIAL.   DENTAL    PATHOLOGY. 

3.  General  appearance  of  the  entire  mucous  membrane  of 
the  mouth. 

4.  Condition  of  mouth  as  to  cleanliness. 

5.  Inflammations  caused  by  deposits  of  salivar^^   calculus. 

6.  Gingivitis  caused  by  deposits  of  serumal  calculus. 

7.  Injuries  to  gingivjp  caused  by  open  contacts  or  bad  con- 
tacts ;  by  imperfect  margins  of  fillings  or  crowns,  etc. ;  or  ])y 
abuse  of  the  tissues  in  dental  operations. 

8.  Injuries  caused  by  misuse  of  toothpicks,  rubber  bands, 
brushes,  etc. 

9.  Detachments  of  the  peridental  membrane. 

10.  Chronic  alveolar  abscess. 

11.  Hyperemic,  inflamed  or  dead  pulps. 

12.  Caries. 

In  the  actual  examination  a  definite  routine  should  be  fol- 
lowed which  will  include  all  of  the  above,  although  it  is  not 
necessary  to  make  a  separate  survey  of  the  mouth  for  each  item 
mentioned.  The  plan  presented  herewith  will  be  found  to  be 
very  satisfactory.  It  is  not  important  that  this  particular  plan 
be  followed.  An}'-  other  which  covers  the  field  will  do  as  well. 
It  is  of  the  utmost  importance,  however,  that  each  dentist  train 
himself  into  the  habit  of  following  a  regular  plan  in  order  that 
nothing  may  be  overlooked.  Each  condition  should  be  recorded 
as  the  examination  proceeds.  A  detailed  statement  of  a  simple 
plan  of  making  this  record  will  be  given. 

Instruments  for  routine  examination. 

The  following  instruments  should  be  on  the  operating  tray, 
or  conveniently  at  hand,  for  this  examination: 

Mouth  mirror. 

Three  explorers,  one  almost  straight,  and  a  pair  of  right 
and  left  curved  instruments. 

Pair  of  peridental  membrane  explorers. 

Cotton  pliers. 

Cotton. 

Silk  floss. 

Air  syringe. 

Water  syringe,  and  warm  water. 

In  addition  to  the  above,  a  mechanical  separator  will  often 
be  required  for  examination  of  proximal  surfaces.  Also  a  sharp 
steel  probe  should  be  used  to  explore  practically  every  sinus, 
and  occasional!}^  a  soft,  blunt  silver  probe  will  be  needed. 


EXAMINATIONS    OF    THE    MOUTH.  451 

Tlio  examination  should  consist  of  a  general  survey  of  tlio 
entire  nioutb,  followed  by  a  more  critical  inspection  of  the  teeth 
and  adjacent  tissues  of  the  lower  jaw,  then  a  similar  inspection 
of  the  upper.  For  the  general  survey  the  chair  should  be  tipped 
about  half-way  back ;  for  the  inspection  of  the  lower  teeth  and 
soft  tissues  it  should  be  upright;  for  the  uppers  it  should  be 
tipped  far  back. 

General  survey. 

For  the  general  survey  the  lips  should  be  retracted  iio  as  to 
give  the  best  possible  view,  first  of  one  side  of  the  mouth,  then 
of  the  other.  The  patient  may  then  be  asked  to  close  the  teetli 
so  that  the  occlusion  may  be  noted.  The  general  condition  of 
the  teeth,  as  to  atrophy  or  hypoplasia,  erosion  or  a})rasioii, 
should  be  observed;  also  an  estimate  should  be  made  of  the 
extent  and  condition  of  previous  dental  operations.  The  entire 
mucous  membrane  should  be  carefully  inspected,  noting  points 
of  swelling,  abnormal  redness,  sinus  openings,  or  any  almornia! 
conditions.  The  condition  of  the  mouth  and  teeth  as  to  cleanli- 
ness should  be  carefully  observed  at  this  time ;  also  the  general 
condition  as  to  deposits  of  salivary  calculus.  The  mouth  mirror 
should  be  used  for  the  examination  of  the  lingual  surfaces. 

In  this  survey  a  good  general  idea  will  be  had  of  the  con- 
ditions presenting  in  the  particular  mouth.  The  number  of 
fillings,  the  number  of  teetli  missing,  the  extent  of  decays  which 
may  be  observed,  the  general  condition  of  previous  operations, 
the  cleanliness  or  lack  of  cleanliness,  together  with  the  age, 
the  apparent  general  manner,  physical  and  nervous  condition, 
should  enable  the  dentist  to  form  a  good  opinion,  not  only  of  the 
condition  of  the  investing  tissues  and  the  susceptibility  of  the 
patient  to  caries,  but  of  the  problems  and  difficulties  to  be  met 
both  in  the  operations  to  be  performed  and  in  the  direction  ;ni(l 
training  of  the  patient  in  mouth  hygiene. 

Critical  examination  of  the  teeth  and  investing  tissues. 

A  I'egular  routine  should  be  followed  for  each  arch,  and  the 
examination  of  the  lower  arch  should  be  com])leted  befoi-e  chang- 
ing the  T)osition  of  the  chair  for  the  examination  of  the  upper 
arch.  As  good  a  plan  as  any  will  be  to  begin  with  the  third 
molar  on  the  left  side  and  pass  gradiinlly  around  tlie  aicli  to  the 
right  third  molar. 

The  investing  tissues  should  be  examined  fii'st,  begimiing 
with  the  crests  of  the  gingiva*.     iJecessions  and  iiillMmmations  of 


Chart  for  Examinations  of  the  Mouth 


General  Survey. 

Conditions. 
Occlusion. 


1. 
2. 

3. 
4. 


Cenoral  condition  of 
tooth  as  to  decay. 

General  condition  of 
mucous  membrane. 

General  condition  of 
mouth ;  cleanliness 


Routine  to  Be  Followed. 
Chair  tipped  half  way  back. 

Suggestions  for  Entries  c)N  Record. 
Nonnal,  or  class  (Angle),  or  indicate  particu- 
lar tooth  with  arrows. 
Good.     Immune.    A^ery  susceptible.    Previous 

tillings  good,  etc. 
(Jood.    17.    18.    19. 


Good.     70  or  subdivisions. 


Chair  upright 


6.     Septal  gingivas. 


Critical  Examination  of  Teeth  and  Investing  Tissues. 
for  lower  jaw,  far  back  for  upper  jaw. 
5.     Labial,    buccal    and    Recessions,  17. 

lingual  gingivae.  Salivary  calculus,  18. 
Serumal  calculus,  19. 
Imperfect  margins  of  fillings,  crowns,  etc.,  40 

and  subdivisions. 
Abuse  of  tissues  in  operations,  50  and  sub- 
divisions. 
Lack  of  cleanliness,  60  and  subdivisions. 
Errors  in  cleaning,  70  and  subdivisions. 
Lack  of  contact,  20  and  subdivisions. 
Improper  contact,  30  and  subdivisions. 
Imperfect  margins  of  fillings,  crowTis,  etc.,  40 

and  subdivisions. 
Abuse  of  tissues  in  operations,  50  and  subdi- 
visions. 
Lack  of  cleanliness,  60  and  subdivisions. 
Errors  in  cleaning,  70  and  subdivisions. 
Enter  depth  in  millimeters,  1-15  (Table  2),  or 
use  1,  2,  3,  as  indicating  shallow,  medium 
and  deep,  without  actual  measurement. 
Digital  examination,  Write  word  absorption  or  pus. 
absorptions  of  bone, 
presence  of  pus. 
Exploration,    sinuses.  Write  word  abscess,  or  C  (see  Table  2). 
Condition  of  pulps.      T,  or  subdivisions  in  Table  2. 
Order,    radiographs.    Small  x  above  tooth. 

Caries,  atrophy,  Sj'mbols  for  caries.     ]\Iark  location  of  others 

abrasion,  erosion.  with  red  ink,  enter  word  for  condition. 
Note. —  This  chart  has  been  prepared  as  a  guide  to  be  followed  in  mouth 
examinations.  After  each  item,  memoranda  are  given  for  the  entries  to  be  made  in 
making  the  record.  If  copies  of  this  chart  and  the  accompanying  tables  are  placed 
where  they  may  be  conveniently  referred  to  and  followed  for  a  time  in  making 
mouth  examinations,  one  will  soon  become  familiar  with  most  of  the  details.  It  will 
be  observed  that  there  are  two  tables  of  numbers,  letters  and  symbols;  one  enabling 
the  operator  to  record  much  closer  detail  than  the  other.  One  may  follow  the  more 
simple  plan  of  Table  No.  1  for  a  time,  until  he  is  familiar  with  it  and  then  change 
to  Table  No.  2.  In  doing  this  there  will  be  no  confliction.  In  recording  inflamma- 
tions of  the  gingiva",  for  example,  the  numbers  in  Table  No.  2  give  a  more  exact  state- 
ment of  causes  than  do  the  numl>ers  in  Table  No.  1.  See  illustrations  .502  to  507,  which 
show  a  suflScient  variety  of  entries  to  make  the  plan  clear. 

(152) 


Detachments  of 
peridental  mem- 
brane. 


9. 
10. 
11. 

12. 


Markings  to  be  Used  in  Recording  Examinations  of  the  Mouth 

SEE  DESCRIPTIONS  OF  FIGURES  501  TO  507. 


Table  No.  1 — Partial  Detail. 


Conditions  of  the   Investing  Tissues. 

16.  Open  contact,  no  inflammation. 

17.  Secession  of  gingiva,  cause  not 
apparent. 

Inflammation,  Due  to 

18.  Salivary  calculus  deposits. 

19.  Serumal  calculus  deposits. 

20.  Lack  of  contact  of  teeth. 
30.     Improper  contact  of  teeth. 

40.  Deviations  from  normal  contour 
—  bad  margins  of  fillings,  crowns,  etc. 

50.  Abuse  in  previous  dental  opera- 
tions. 

60.     Lack  of  cleanliness. 

70.  Injuries  in  mouth  hygiene  technic. 
Depth  of  pockets,  1,  2  or  3,  indicating 
shallow,  medium  or  deep. 


Conditions  of  Pulp,  Etc. 

T      Treatment    required,    without    ref- 
erence to  condition. 
Caries,  Etc.,  Operations. 
°      Pit  or  fissure  decay. 
0      Proximal  decays,  mesial  and  distal. 
3      Gingival    third    decays,    labial    or 

buccal  and  lingual. 
/      Missing  tooth,  previously  extracted 

or  unerupted. 
X      To  be  extracted. 
O      To  be  crowned. 
^      Dummy. 
I      Partial  denture.    Line  through  each 
tooth  and  these  lines  joined. 
Full   denture,   write   same   on  dia- 
gram. 


Table  No.  2 — Complete  Detail. 


Conditions  op  the  Investing  Tissues. 

16.  Open  contact,  no  inflammation. 

17.  Kecessiou    of    gingiva,    cause    not 
apparent. 

Inflammation,  Due  to 

18.  Salivary  calculus  deposits. 

19.  Serumal  calculus  deposits. 
Lack  of  Contact  of  Teeth. 

21.  Separations  following  extractions. 

22.  Abnormalities  of  occlusion. 

23.  Uneven  occlusal  wear. 

24.  Weak  contact. 

25.  Proximal  decays. 

26.  Fillings  or  crowns. 

27.  Loss  in  width  of  neighboring  space. 

28.  Detachment  of  trans-septal  fibers. 
Improper  Contact  of  Teeth. 

31.  Abnormal  forms  of  teeth. 

32.  Malpositions  of  teeth. 

33.  Interproximal  wear. 

34.  Improperly    finished    fillings    and 
crowns. 

Deviations  from  Normal  Contour. 

41.  Sharp  edges  of  cavities. 

42.  Imperfect  margins  of  fillings. 

43.  Imperfect   margins  of  crowns. 
Abuse  in  Dental  Operations. 

51.  Injuries  with  ligatures. 

52.  Injuries  with  finishing  instruments 
and  tapes. 

53.  Failures  to  remove   ligatures  and 
pieces  of  rubber. 

Lack  op  Cleanliness. 

61.  Lack  of  natural  cleaning  in  masti- 
cation. 

62.  Lack  of  artificial  cleaning. 
Errors  in  Cleanini;  Operations. 

71.  Misu.se  of  tootlipicks. 

72.  Misuse  of  rnltlxT  liiiuds,  silk  floss. 

73.  Injuries  with  tooth-brush. 


Conditions     of     Investing     Tissues  — 
Continued. 
Detachments  of  Peridental  Mem- 
brane. 
1  to   15.     Depths  of  pockets  in  milli- 
meters, measured  with  special  graduated 
explorers.     (See  Figure  267.) 
Conditions  of  Pulp,  Etc. 

T      Treatment    required    without    ref- 
erence to  condition. 
N     Normal. 
H     Hyperemia. 
E      Exposed  and  alive. 
D      Dead. 

E      Previous  root  filling, 
A      Acute  alveolar  abscess. 
C      Chronic  alveolar  abscess. 
Radiographs. 

X      Small  cross  above  each  tooth  roots 
and   alveolus   of   which    is   to   be 
shown  in  radiographs.     Red  ink 
preferred  for  this. 
Caries,  Etc.,  Operations. 
^      Pit  and  fissure  decay. 
0      Proximal  decays,  mesial  and  distal. 
3      Gingival    third    decays,    labial    or 

buccal  and  lingual. 
/      Missing  tooth,  previously  extracted 

or  unerupted. 
X      To  be  extracted. 
O     To  be  crowned. 
=      Dummy. 
I      Partial  denture.    Line  through  each 
tootli,  and  tlieso  lines  joined. 
Full  denture.     Write  same  on  dia- 
gram. 
Atropliy,    abrasion,    erosion    to    be 
marked  with    rod   ink  and   name 
on   bottom   line   to   indicate   con- 
dition. 


(•453) 


454  SPECIAL    DENTAL    PATHOLOGY. 

the  buccal  and  labial,  then  of  the  lingual  gingiva?,  should  be 
noted;  also  deposits  of  salivary  calculus,  improper  margins  of 
fillings  and  crowns,  and  other  causes  of  the  different  areas  of 
inliamniation.  Then  the  septal  gingivae  should  be  carefully  exam- 
ined for  areas  of  inflammation.  The  cause  of  each  area  of 
gingivitis  should  be  determined,  the  search  being  l)ased  ujion  a 
knowledge  of  the  wide  variety  of  conditions  presenting.  This 
will  include  an  examination  of  the  contact  in  each  case  in  which 
a  sei)tal  gingiva  is  inflamed.  It  may  lead  to  inquiry  into  the 
])atient's  habits  of  cleaning,  the  misuse  of  toothpicks  or  silk  floss, 
the  kind  of  tooth-brush,  the  motions  made  with  the  brush,  etc. 
All  inflammations  of  the  gingivje  call  for  an  instrumental  exam- 
ination of  the  subgingival  spaces  for  deposits  of  serumal  calcu- 
lus. Sharp  pull  scalers  will  usually  be  preferred  to  the  peri- 
dental membrane  explorers  for  this  purpose.  For  adults,  the 
subgingival  spaces  to  the  lingual  of  the  upper  incisors  should 
always  be  examined  for  these  deposits. 

The  peridental  membrane  explorers  should  next  be  em- 
ployed to  determine  whether  or  not  there  have  been  detachments 
of  the  membrane  from  the  cementum.  Such  instruments  may 
be  carried  into  the  subgingival  spaces  until  they  meet  the  attach- 
ment to  the  cementum,  and  may  then  be  passed  around  the  tooth, 
noting  any  deviations  from  the  normal  line.  The  depth  and 
positions  of  pockets  may  be  noted. 

Absorptions  of  bone  of  the  alveolar  process  on  the  labial  and 
buccal  sides  of  the  arch,  in  cases  of  chronic  pericementitis,  may 
1)0  noted  by  digital  examination.  The  fiuger,  passed  along  the 
nmcous  membrane,  will  detect  positions  where  the  bone  is  miss- 
ing, and  something  of  the  contour  of  the  root  may  often  ]>e 
made  out.  On  account  of  the  thickness  of  the  investing  tis- 
sues, absorptions  to  the  lingual  of  the  arch  can  not  so  often  be 
detected.  In  cases  of  chronic  abscess,  absorptions  which  have 
involved  the  bone  to  its  surface  may  be  discovered;  or  enlarge- 
jnents  resulting  from  the  building  of  new  bone  will  be  found. 

As  a  part  of  this  digital  examination,  pressure  may  be  made 
on  the  sides  of  the  arch  to  determine  whether  or  not  pus  is 
present  in  a  pocket,  by  forcing  it  out  at  the  gingival  line.  Teeth 
may  be  tested  as  to  their  firmness  in  their  respective  sockets. 

If  there  is  a  sinus,  it  should  l)e  explored  to  find  its  source, 
the  sliarp  steel  probe  being  generally  used  for  this  purpose. 
Tf  the  sinus  is  of  some  length  and  tortuous,  the  blunt  silver  probe 
will  be  better  to  follow  it.     As  has  l)een  emphasized,  it  is  of  the 


J>ate 

NcLTme. 

:lclress 

Ac 

R           1         i  sep\t^l   1         1         1         1        1 

\cj)n,\fi'i\ja^         1 

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isinn                                                                    C 

jeneral  Con 

dition,  Teetl 
_  Cleanlines 

1 

Muc 

niis  Memhrane 

s 

Sex    and   acfc 

1 

FiG.  501. 


Fig.  501.  Tlio  K.\aiiiiii;ili(iii  Ciird.  Size  ;i  liy  5  iiiclus.  'I'lic  (i^^urcs  ri'inusoiit 
the  upper  teeth  on  either  side  of  the  mouth;  1,  central  incisor;  '2,  lateral  incisor;  A, 
cuspid,  etc.  The  letters  repre.sent  the  lower  teeth  on  either  side.  The  patient  is 
supposed  to  be  facing  the  operator  and  tiu'  rigiit  and  left  siilcs  of  the  mouth  are 
indicated  by  K  and  L  in  the  corners  of  the  diagram.  The  occlusal  surfaces  and 
incisal  edges  of  the  teeth  are  supposed  to  be  directi'd  toward  tiie  o|)('rator,  therefore 
the  buccal  surfaces  of  the  upper  teeth  would  be  n|>.  and  the  buccal  surfaces  of  the 
lower  teeth  would  be  down.  It  will  be  n;>ticed  that  there  is  a  rectangular  space  on 
either  side  and  one  above  and  one  Ixdow  each  figure  or  letter;  nundu-rs  may  be  |)laced 
in  these  spaces  to  indicate  the  condition  of  the  investing  tissues  on  the  nu-sial,  liuccal, 
distal  or  lingual  sides  of  ladi  tuipth.  Tliei>'  is  aiiutlier  luw  of  rectangular  spaces  at 
the  top,  and  one  at  the  b<illiim  ut'  the  diayi.-iin:  luimliers  may  be  placed  in  these  to 
indicate  the  i-omlilidii  of  llie  se|ital  lissur  .-ind  of  ihi>  c<iiil;ict.  .S.t  markin<,fs  on  other 
illustrations. 

This  j)laii  of  using  liguies 
teeth,  enables  one  to  liaiisfci'  the 
ledger.  For  example,  in  h'igure  . 
upper  right  tirst  nu)lar;  this  can 
tooth  is  on  the  I'iglit  side.  Tiie  m 
illustration,   would   be  written  ;ilo 


ud  111  Ins,  iuslead  of  diagrams,  to  designate  the 
cM-oiil  for  a  siu;ile  toolii  from  ilaybook  to  record  or 
11'.  a  cavity  is  m.arked  in  the  nmsial  surface  of  the 
(•  written  alom-  as  (i)  '< .  the  Mm'  indicating  that  the 
■;ial  of  the  lower  (irst  nml.-ir  on  the  left,  in  tln^  same 


*41 


2.0 


l(> 


Zo\  \ Zo  \3o 


f 


4d      x 


V  \\\^\\ 


^ 


I 


T 


I 


IS    js: 


jS 


I 


T 


Orrliisinn^^n^^a/  l^tnUIIS General  Condition,  Teeth  .  Qiy-O-cL. 


Mucous  Membrane   <S<«^/  ^^j^J  ^'i^jkAi^^die^  Cleanliness     a  ctO;:^ 

F3^ 


Fic.  .')()2,  A. 


Fig.  502,  A.  Rccunl  of  Kxiiiiiiiuitiuii.  (Marks  from  Tal)le  Xo.  1.)  Patient, 
M'oinan  of  thirty-oigiit  years.  General  condition  of  teeth  as  to  susee|itiliility  to  c-aries, 
good;    general  condition  of  miicons  membranes,  good.     Care  of  month,  good. 

In  the  upper  arch,  both  third  molars  are  missing;  there  is  a  cavity  in  the  mesial 
surface  of  tlie  right  first  molar,  there  is  an  open  contact  between  the  bicuspids,  the 
septal  gingiva  l)eing  inflamed  (20),  and  there  are  deposits  of  serumal  calculus  (19) 
on  the  proximal  surfaces  of  these  teeth.  There  is  an  open  contact  between  the  right 
central  and  lateral,  but  the  septal  tissue  is  not  inflamed  (Ki).  There  is  an  inflam- 
mation of  the  gingiva  to  the  mesial  of  the  left  lateral  on  account  of  some  abuse  in 
operating  (50).  The  left  cuspid  is  to  tlie  labial  of  the  line  of  the  arch  as  indicated 
by  the  arrow,  and  there  is  an  inflammation  of  the  septal  gingiva  between  the  cusjdd 
ami  lateral  on  account  of  lack  of  contact  of  these  teeth  (20).  There  is  an  inflamma- 
tion of  the  gingiva  to  the  buccal  of  the  second  bicuspid  due  to  a  bad  margin  of  a 
filling  or  crown  (40).  There  is  an  inflammation  of  the  septal  gingiva  to  the  mesial 
of  this  tooth  on  account  of  an  ojien  contact  (20),  and  to  the  distal  of  it  on  account  of 
an  improper  contact  (30).  The  first  molar  has  an  abscess,  and  the  little  cross  shows 
that  a  radiograph  is  to  be  madi'.  It  is  marke<l  to  be  crowned,  tlie  (niestion  mark 
indicating  that  this  operation  is  in  dmdit  on  accimnt   of  tln^  abscess. 

In  the  lower  arch,  there  are  ileposits  of  salivary  calculus  (IS)  to  tlie  lingual  of 
the  lower  incisors,  there  is  a  mesial  cavity  in  the  lower  l(>ft  first  molar,  and  the  pulp 
requires  treatment  (T).  The  right  second  bicuspid  is  missing  and  the  first  and  third 
molars  are  to  be  extracted.  A  bridge  is  to  be  i)laced  from  the  second  molar  to  the 
first  bicuspid.  The  first  bicuspid  is  marked  for  jmlp  treatment  (T).  Tlie  second 
molar  is  marked  for  a  radiograph. 

Compare  with. description  of  Figure  5(i2.  B. 


n. 


/6 


j.>  I  >6|34< 


^  ^.f 


(0 


/^ 


// 


S2 


(I 


Orrliisinn   A^^^t/H-ca^^  i^ctJ^A      /J         General  Condition,  Teeth  ^_ 


O-9-oC. 


Mucous  Mpmhrane  ^»»^/  ^etJff'  Out    kt^fU^Atl^    Cleanliness    o  o-Q-fL, 

J^Jl ^ 


Fig.  502,  B. 


Fig.  502,  B.  Kci-onl  of  lv\;iiiiiii;itiiiii.  (.M;iiks  1  luiii  Talilf  No.  2.)  This  is  tlii> 
same  case  as  in  Figure  5i)2,  A.  The  use  of  the  more  (•om])iete  detail  in  recording  will  lie 
understood  from  a  comparison  of  the  two.  The  differences  are  as  follaws:  In  the 
upper  arch,  in  A,  an  open  contact  is  marked  between  the  right  Ijicuspids  (20).  In  B, 
tlie  number  27  shows  the  open  contact  to  be  due  to  a  Hat  proximal  filling  or  cavity  in 
a  neighboring  tooth.  Afiparently  these  teeth  have  sejiarated  on  account  of  the  cavity 
in  the  mesial  surface  of  the  first  molar.  In  A,  an  injury  in  operating  is  recorded  on 
the  mesial  surface  of  the  left  lateral  (50).  In  B,  the  numl)er  52  shows  this  to  be 
due  to  an  injury  by  a  finishing  instrumciil.  and  tlirrc  is  a  pocket  '?>  nun.  ileep.  In  .\. 
an  open  contact  is  recorded  between  tlic  left  latrral  and  cus])id  (2o).  In  B,  the 
luiniber  22  shows  this  to  be  due  to  an  abnormality  uf  ncidnsion.  [ii  .\.  anotiu'r  open 
contact  is  record(  d  between  the  bii-nspids  (20).  In  I!.  Ilie  Mundier  2(i  shows  this  to  lie 
due  to  lack  of  ((inlac'  of  a  filling  or  crown.  In  .\.  tlieie  is  ;in  intlainniat  ion  to  the 
buccal  of  the  first  nmlar.  t\\\v  to  a  deviation  fioin  llie  nniinal  smooth  cont(mr  (-fO). 
In  B,  the  nundier  l.'!  shows  this  to  be  due  to  the  inarg !n  of  ;i  crown.  In  .V.  tlu're  is 
recorded  an  inllammal  ion  of  the  septal  gingiva  between  the  second  bicuspbl  :iinl  lii'^if 
molar,  due  to  an  improper  coiitact  (.".0^.  In  15.  the  nu'niier  :!  I  shows  this  In  bi'  iUw 
to  an   inipi'eperly    formed   (illing  oi-  crown. 

In  the  lower  jaw,  in  .\,  the  pulp  nl'  the  lower  left  first  nn)!ar  is  marked  for  trial- 
nniit  (  T  I .  In  I'.,  it  is  shown  that  this  judp  is  exposed  .-ind  alive  (K).  On  1l;e  huxer 
right    side,   the   letter   .\    iudiciitcs  Ih.at    a    norni;il   pulp   is  to   be   removed    from    the    lir-t 

bicuspid    and    the    l\    th:if    the    root    c;in;ils    of   the   y( nd    nnd.ar    ha\e    been    filled    by   a 

previous    oper.ator.      There    is   apparent     no    sign    of   an    abs-i-;s;      iIk'    radiograph    Ii:m 

been  oi'dered  to  learn   ll ondition  of  llic  canals  and  of  the  bone  about   flu-  apex. 

It  ie<|nires  only  a  little  niori'  lime  In  becmne  familiar  with  T:ible  \o.  2,  and  oiu' 
is  then  able  to  make  belter  re-.-ord-;  willionl  <pccnpying  nmre  linw  in  marking  the  cards. 


J.^cJb^^ ,  h%i^^    UJ'  /, 


^u  6^  I  bJ^ 


Tl 


wy\7 
71) 


( ) 


L\) 


C) 


5 


i-    ^t-  i^^- 


((i 


z 


V 


z 


z 


A- 


^  Z-      /^  I  ^^^     ^T^ 


^ 


ifU-    l>>^    (>>-    l>>^ 


Occlusion_iLer^k*i!:±rl 

Mucous  Memhrnne       ^  O-O-xL^ 

IJI 


General  Condition,  Teeth  l/f/{^^    4aaA. OLyA^lyCuie 


Cleanliness. 


Fig.  5()o. 


Fifr.  .lo.'^.  Ix'c-iird  of  Kxainiiiatioii.  (Marks  from  Table  No.  2.)  Patient,  girl 
of  eighteen  years.  Occlusion  normal.  Susceptibility  high  to  caries.  Mucous  mem- 
branes, good.  The  number  (52  indicates  improper  artificial  cleaning  of  most  of  the 
bicusjjids  and  molars,  and  there  is  one  gingival  third  decay  in  the  lower  left  first 
molar  because  of  this.  Patient's  attention  is  called  to  the  condition  at  the  time  of 
the  examination  and  is  told  how  to  brush  these  teeth  and  the  kind  of  brush  to  use. 
When  she  returns  for  subsequent  operations,  the  card  reminds  the  dentist  of  this,  and 
her  care  is  criticized  from  time  to  time.  Tlii-ec  or  four  months  later,  when  |)atient 
returns  for  anothci-  examination,  the  canl  again  reminds  the  dentist  to  criticize  tlie 
care  of  these  areas. 

There  are  mesial  and  distal  ca\ities  in  the  four  u|i|)er  incisors,  ;in  occlusal  ca\ity 
in  the  up])er  right  second  molar,  a  mesial  caxity  in  the  ujijier  left  first  molar,  and  a 
mesial  cavity  in  the  lower  right  first  molar.  There  was  some  question  at  the  time  Af 
the  examinjition  as  to  whethei-  or  not  (lie  |inlp  of  this  tooth  tniglit  b(>  (>x|iosed,  as  indi- 
cated by  the  question  mark  before  the   letter   Iv 

The  check  marks  indicate  that  at  tlie  time  lliis  card  was  iihotogniphed,  tlie  filling 
had  been  placed  in  the  lower  right  first  molar,  also  that  three  fillings  had  been  placed 
in  the  upper  incisors.  By  checking  each  oi>eration  as  it  is  recorded  on  the  permanent 
record,  the  operator  has  before  hini,  at  each  return  of  patient,  an  exact  memoramlum 
of  what  has  been  done  and  what  remains  to  be  done. 


-^ 


^g,  /f/z^ 


STi^i   ^ly^AjuJL^,  ^ 


Occlusion 


Mucous  Membrane. 

1^ . 


General  Condition,  Teeth 

Cleanliness    o  2-^ 


O^M^^J^     yi.OLALofA.OL.jihA       4     cuU 


Fig.  504. 


Fig.  504.  Record  of  Exaniiuatioii.  (Marks  from  Table  No.  2.)  Patient, 
Avonian  of  forty-seven  years.  Referred  by  Dr.  I..  J.  Kolien,  with  request  for  report 
on  mouth  as  probable  "focus  of  infection.  The  reconl  shows  a  mouth  not  well  cared 
for  by  the  patient  (62).  with  deposits  of  salivary  calc\ilus  (18)  on  the  buccal  of  the 
upper  molars,  also  on  the  lingual  and  proximal  surfaces  of  the  lower  six  front  teeth. 
and  on  the  labial  surfaces  of  the  four  incisors. 

In  the  upper  arch,  on  the  right  side,  the  contacts  between  the  molars  are  weak 
(24),  permitting  food  to  be  forced  through.  There  are  pockets  3  and  4  mm.  deep  on 
the  proximal  surfaces  of  these  teeth.  The  septal  gingiva  between  the  bicuspids  is 
inflamed  because  of  tlic  \\\o  j.roximal  cavities  (25).  There  are  pockets  of  various 
depths  —  from  2  to  (i  mm.  on  tlie  lingual  and  jjroximal  surfaces  of  the  incisors  and 
right  cuspid.  Deposits  of  scniinal  calcuhis  arc  indicatcil  on  all  of  these  surfaces 
(19).  Pus  was  discovered  to  tlic  lingual  of  the  right  latii;il  and  both  centrals. 
There  is  inflammation  l.ctwc.'u  the  iipiin-  lift  sci-ond  biciis|.id  and  first  nu 
a  filling  or  crown  which  failed  to  make  coiitai-t  (I'li).  Thciv  arc  |iockcts  4 
deep,  and  deposits  of  soiaiinai  calcidus   (lii). 

In  the  lower  Jaw,  in  addition  to  the  deposits  of  salivary  calculus 
pockets  on  the  Ungnal  snrfaces  of  the  first  ami  second  molars  .">  nnii. 
deposits  of  serumal  calculus  (19).  There  is  a  deposit  on  the  entimel  of  the  lingnal 
subgingival  space  of  the  second  bicuspid  (19),  l)ut  no  ])ocket.  There  are  pockets  on 
the  "^proximal  surfaces  of  the  bicuspids  iind  molars,  :?,  4  and  5  mm.  deep,  but  no 
deposits.  Pus  was  found  in  two  of  these.  The  conf.act  bi>tween  the  second  bicuspid 
an<l  first  molar  is  open  as  a  result  of  the  cnttin-  (dV  of  the  t  la  ns-sc|.tal  libers  which 
normally  pass  from  tooth  to  tooth   (2S). 

On  the  lower  left  side  the  first  ninlni'  is  missiiig  and  the  bicuspids  have  moved 
distally,  opening  the  contacts  and    |"rinit  t  ing   an    inllamniat  ion    cd'    the    si'pt.al    tissues 

(21).  "  A  gingival   third    (illing  in   the   bnccai   siirfa )f   the  second    ni 

margin  an<l  the  gingiva   is  inflamed    (  12). 

Kadiograiihs  were  ordered    for  the  entii'e  month. 


ir.  due   to 
ml  :'i   mm. 

there    a I'e 
leeji,    witii 


bad 


/j  aJ^yt<y^^ 


\^a/iyy^^ 


7h 


CLyX^&jL^yi, 


// 


^-^v-i^ 


^_    /f/S^ 


j.y^  yy   /o^s^ 


mXKi 


I 


71 


M- 


7/  I  7/  I  7H  7H  7/  I         I  I 


^^o-in-e. 


Occlusion 


Mucous  Membrane. 


General  Condition,  Teeth 


Cleanliness     P  2^'_ 


yyi^   ^Z--  Ziyiyi/-ey^  Xoa/Za^  /^y( e^-XH    yyyf^^  Xt/yl^v*'^iA ^-A^-t^--^ 


Fig.  nn 


Fijj.  505.  Rec'dicl  df  i''x-uiiin;iti(>ii.  (M;irks  I'loiii  'I'nhlc  No.  2.)  I'.-iticnt,  man 
of  fifty-two  years.  Tlicrc  is  a  iiciicral  lai'k  ol'  care  ((i"_').  Ii:  tl'.c  ii|)|jcr  an-li  tlicrc 
is  a  mesial  decay  in  llic  rijjlit  first  iii()lar  and  a  ii'iii<ii\  :il  lliini  (jccay  in  the  labial  surface 
of  the  ciisj)i(l.  'I'lic  liiiper  left  second  l»i('iis|)id  ami  di'^t  nmlai-  aic  In  lie  cxtracteil  on 
account  of  disease  of  the  peridciila!  incinlna  iic  and  a  liridyc  is  to  he  ])lacM'd  frmn  the 
second  molar  to  the  first  l)i<'ns]iid.  liadidi^rajihs  (if  lliese  I'oots  arc  to  lir  m-dcird. 
Both  thinl  molars  are  missing. 

In  the  lower  jaw,  the  septal  tissues  lielween  the  front  teeth  have  been  injureil  hy 
the  misuse  of  the  toothpick  (71).  There  ;ire  de|M)sits  of  salixary  calculus  on  the 
linirnal  of  the  six  front  teeth,  linlli  tliiid  molars,  the  left  first  molar  and  the  right 
l)icuspids  are  missing,  the  riniainiii;^  nmliirs  and  let't  second  bicuspid  are  to  be 
extracted  on  account  of  disease  of  ihe  |iei-idental  mendoane.  Three  of  these  teeth 
are  loose.  A  partial  denture  is  to  1h'  niad<'  replacing  Ihe  birnsjiids  and  in(dars  on  the 
right  side  and  the  second  bicuspid  and  two  nidlars  mi  the  left  side.  Tins  plate  is  to 
liave  a  lingual  bar  and  clasps  on  the  riglit  cuspid  and  left  secnnd  bicuspid. 


Occlusion^ 


General  Condition,  Teeth  _       _, 

Mucous  Membrane^/^^ Cleanliness    ° 


V\)i.  .Iik;.  KN.,.,)1-(1  (if  lv\;iiniii;iti.iii.  (M,-iiks  i'ni:n  T.-iliir  Xo.  L'.)  Tlic  :i1m.v<>  is 
M  i-c|ir()(|iictiiiii  (if  tlif  rt'Ciird  of  llic  ■.\.i,iiii,;i1  idii  (if  llic  iikhiIIi  df  ;i  man  (if  furt y-cijrlit, 
l>rcvi(His  t(i  the  inakiny  of  tlic  ra(liii^':i|iliN  sIkiwii  in  l-'iL;nics  i'.",  I  and  L':'..').  The  idVort 
was  made  to  iccoi-d  the  dcptli  of  Ihc  ].ock(ls  on  cacli  side  of  cadi  idot,  nicasuri'd  from 
tlio  ju-in«-ival  line,  and  llic  li^^nics  to  tlic  mesial  and  distal  of  ca(di  tooth  may  lie  com- 
pared with  the  alisorptions  of  Ixme  shown  in  the  ladioiiiajilis.  It  will  lie  noticed  that 
pockets  were  not  marked  aliont  the  lower  first  liiciispids.  and  the  lioiic  aliout  tlic^e 
teeth  is  normal  or  \-ery  nearly  so  in  the  radio^ra  jihs.  This  will  ^ive  a  ydod  idea  of 
t  he  \a  I  IK    of  smdi  a    record  in  show  ini;  t  he  ai  t  iia  I  conditions. 

'I'his  jiatient  had  liccn  piactically  iinmnne  to  dental  caries  all  his  life,  and  had 
never  taken  proper  care  of  his  month.  <leanin>r  was  unnecessary  for  caries,  and,  like 
iiiany  ]»ei'sons  who  aic  apparently  so  fortnnate,  his  haliitnal  lack  of  care  conid  not  lie 
chan^red  to  jireNent  the  loss  of  his  teeth  later  in  life  from  disease  of  tiie  investinjj 
tissues.  It  will  lie  noted  that  there  were  deposits  of  salivary  calcnins  (IS)  aliont  the 
lower  incisoi's,  and  deposits  of  sii-nnial  calcidns   (  Mt)   yeiieral'ly  aliont   the  teeth. 

As  noted  in  the  desci  i  |it  ions  of  M^nres  I'.W  and  L'.'Jo.  this  patient  wa>^  advised  to 
liave  all   of   his  teeth  extracted. 


llboLAJUy.     yyiAA^^     fhM^y^^x^^ 


A^  /?,  (Ill- 


~7~**  I       V,^  OU^-^xjUL     X^ 


R                 i        1        1        1        1        1        1        1        i        1        1        1        1        ILI 

1 

7T 

f« 

t' 

'* 

^ 

1 

1 

1 

'1 

1^ 

t 

(Y 

I 

// 

// 

\ 

i 

f 

i; 

t 

/ 

k 

'  f/4 

°r 

// 

R!        1 

-^ 

1 

1 

! 

i 

1 

^ 

L^ 

1 

|L 

Occlusion, 


Tt/^^'T.^Kyt^ 


Mucous  Membrane, 


General  Condition,  Teeth 

Cleanliness 


yn  /o 


Fig.  507. 


Fig.  507.  Eecord  of  fi.xamination.  This  boy  of  ten  years  was  taking  fair  care 
of  his  teeth.  His  occlusion  was  normal.  All  second  (permanent)  and  third  molars 
are  iinerupted. 

In  the  upper  arch  the  tciii|.i>rary  (•tisj)i(ls  and  first  and  sccund  molars  are  in  place 
(indicated  by  roman  numerals).  There  are  three  proximal  cavities  in  these,  and  an 
occlusal  cavity  in  the  right  first  molar.  There  is  also  a  buccal  pit  cavity  in  the  left 
first  molar. 

In  the  lower  jaw,  mi  the  right  side,  the  ti'iiiporary  molars  remain  (indicated  by 
script  loAver-case  letters),  and  the  first  molar  has  an  occlusal  cavity.  On  the  left  side, 
the  temporary  cuspid  and  second  molar  remain;  the  temporary  first  molar  has  been 
lost  and  the  bicuspid  has  not  yet  ernjtted.  There  is  an  occlusal  cavity  in  the  ]H'rmancnt 
first  molar. 

If  such  records  are  kept  of  the  mouths  of  many  children,  made  for  each  child 
every  three  or  four  months,  they  will  come  to  furnish  very  valual)]e  information,  not 
only  of  the  time  of  the  loss  of  the  temporary  teeth  and  the  eruption  of  the  perma- 
nent teeth,  but  of  the  general  progre.ss  of  eases,  the  ages  at  whicdi  decays  of  various 
classes  occur,  etc. 


EXAMINATIONS    OF    THE    MOUTH.  455 

ft-roatest  importance  to  determine  how  much  of  the  end  of  the 
root,  if  any,  has  been  denuded.  This  is  best  done  with  the  sharp 
steel  probe,  and  the  extent  of  the  cavity  in  the  bone,  as  well  as 
the  condition  of  the  bone  itself,  may  be  made  out. 

The  examination  for  pulp  conditions  will  usually  be  in 
response  to  some  complaint  by  the  patient.  These  conditions 
have  been  discussed.  It  is  only  necessary  here  to  call  attention 
to  the  fact  that  in  eases  in  which  the  pulp  is  alive,  the  pain  may 
not  be  definitely  located  by  the  patient,  unless  there  is  an  open 
(^avity  to  direct  the  attention  to  the  tooth.  On  the  other  hand, 
such  a  cavity  may  lead  tlie  patient  into  error  in  locating  pain. 
Thermal  changes  and  actual  contact  of  food,  or  an  instrument, 
are  the  most  certain  means  of  locating  the  teeth  involved.  It 
should  be  remembered  that  the  differential  diagnosis  between 
hyperemic  and  inflamed  pulps  is  based  on  actual  exposure. 

In  cases  in  which  the  inflammation  of  the  pulp  has  extended 
to  the  periapical  tissues,  the  tooth  is  easily  located  by  the  fact 
that  it  is  tender  to  touch,  as  by  tapping  it  with  an  instrument. 
Discolored  teeth  should  call  for  inquiry  as  to  previous  treat- 
ment, to  determine  whether  the  pulp  has  been  removed,  or  the 
tooth  contains  a  dead  pulp. 

Lastly,  one  should  look  to  the  condition  of  the  hard  tissues 
of  the  teeth,  recording  areas  of  erosion,  atrophy  or  hjqioplasia, 
abrasion,  and  caries.  In  this  connection  missing  teeth  should 
be  noted,  and  inquiry  made  to  learn  if  they  have  been  extracted, 
or  have  failed  to  erupt. 

The  examination  for  caries  should  be  separate  for  three 
groups  of  cavities.  First,  one  should  look  for  pit  and  fissure 
decays,  using  an  explorer  and  mouth  mirror.  In  addition  to  the 
occlusal  surfaces  of  bicuspids  and  molars,  the  lingual  surfaces  of 
the  upper  lateral  incisors  and  the  buccal  and  lingual  surfaces  of 
molars  should  alwa3^s  be  examined  for  decays  of  this  class. 
Second,  the  gingival  third  positions  should  be  examined.  These 
should  be  dried  for  this  purpose,  either  with  the  air  syringe,  or 
by  laying  a  roll  of  gauze  on  either  side  of  the  arch.  Many 
beginning  decays,  which  will  not  be  discovered  with  an  instru- 
ment, nor  observed  if  moist,  will  appear  as  whitened  areas  when 
diy.  When  discovered  at  this  time,  their  further  progress  may 
possibly  be  prevented.  Third,  should  come  the  exaniinaiion  oT 
j)roxima]  surfaces.  If  tlie  teeth  are  dry,  citliei-  wliitcned  siiv- 
faces  or  (llscoloi-alions  sliowing  tlu'oiigh  llie  occlusal  ))laies  may 
indicate    decays.      '^riic    p.-iir    of    rii^lii    ;in(I    Icfl    cxpldrcrs    will 


456  SPECIAL    DENTAL    PATHOLOGY. 

usually  locate  proximal  cavities  unless  they  are  very  slight. 
A  silk  floss  should  be  carried  through  each  contact.  It  ^Yill 
usually  be  cut  or  frayed,  or  will  drag  past  the  contact,  if  there 
is  a  decay.  Many  proximal  decays  which  can  not  be  reached 
with  instruments,  will  be  located  with  the  floss.  If  a  second 
attempt  with  the  instrument  fails,  a  separator  should  be  placed 
to  move  the  teeth  apart  sufficiently  to  give  room  for  the  explorer. 
This  will  complete  the  examination.  The  directions  given 
may  seem  a  little  long,  but  if  followed  for  a  time  until  a  routine 
habit  has  been  acquired,  such  an  examination  may  be  in  the 
average  case  carried  out  to  the  last  detail  and  fully  recorded 
within  about  ten  minutes,  if  an  assistant  makes  the  record.  It 
will  require  a  few  minutes  more  if  the  dentist  must  himself 
record  his  findings. 

The  Record  of  the  Examination. 

The  plan  to  be  followed  in  recording  all  of  the  many  little 
details  of  a  thorough  mouth  examination  must  be  so  simple  as 
to  be  easily  made  with  very  slight  expenditure  of  time.  In  fact, 
the  assistant  should  be  able  to  make  the  record  as  the  examina- 
tion proceeds.  A  plan  which  is  too  elaborate  will  be  impractical. 
It  has  been  my  effort  to  develop  a  scheme  fitted  to  the  regular 
routine  examination,  with  definite  means  of  recording  cavities 
of  decay,  the  condition  of  the  investing  tissues  and  of  the  pulp, 
as  they  commonly  present  in  practice,  by  the  use  of  certain 
symbols,  figures  and  letters.  Provision  is  also  made  for  the 
entry  of  other  data  which  are  frequently  desirable  or  necessary. 
Two  tables  of  symbols,  figures  and  letters  are  given;  one  of 
these  provides  for  only  partial  detail  in  entering  causes  of 
inflammations  of  the  gingivpp,  the  other  for  complete  detail  in 
recording  these.  These  tables  are  so  arranged  that  one  may  use 
the  more  simple  one  for  a  time  and  then  change  to  the  other,  or 
parts  of  both  may  be  used  without  confliction  or  confusion. 

The  record  of  the  examination  should  include  all  of  the 
conditions  found,  with  whatever  of  the  previous  history  may  be 
necessary  to  a  complete  diagnosis ;  the  treatment  determined 
upon;  and  a  memorandum  of  the  fees  to  be  charged,  if  that 
question  is  discussed.  Every  item  which  might  be  of  value  for 
future  reference  is  thus  entered  at  the  time.  The  subsequent 
use  to  be  made  of  this  record  will  be  ('Xj)hiined. 


EXAMINATIONS   OF    THE    MOUTH.  457 

This  plan  has  been  gradually  developed  during  the  past 
fifteen  years  and  has  been  used  more  or  less  fully  by  a  goodly 
number  of  practitioners.  While  it  is  by  no  means  as  perfect  as 
might  be  desired,  it  will  enable  one,  with  a  little  ex])erience,  to 
make  a  very  exact  record  without  loss  of  time.  The  plan  is 
referred  to  in  papers  written  in  1904*  and  1912. f 

The  examination  card. 

The  record  is  made  on  a  3  x  5  inch  white  card.  (See  Figure 
501.)  As  will  be  noted  by  reading  the  description  of  the  card, 
the  upper  teeth  are  represented  by  figures,  the  lower  teeth  by 
letters.  There  is  a  distinct  advantage  in  this,  as  compared  with 
diagrams  of  the  various  teeth,  as  it  permits  the  making  and 
transferring  of  the  record  of  a  single  tooth,  so  that  entries  may 
be  made  in  a  daybook  and  transferred  to  a  ledger  or  record  card 
or  book.  It  will  be  noticed  that  there  is  a  rectangular  space  for 
the  purpose  of  recording  separately  the  condition  of  the  soft 
tissue  on  the  mesial,  buccal,  distal  and  lingual  sides  of  each 
tooth.  There  are  two  rows  of  rectangular  spaces,  one  for  the 
upper  jaw  and  one  for  the  lower,  in  which  to  record  the  condi- 
tion of  the  contact  which  is  responsible  for  inflammation  of  the 
interproximal  gum  septum  —  the  septal  tissue. 

Aside  from  the  general  conditions  which  may  be  indicated 
on  the  lines  below  the  diagram,  and  on  the  reverse  side  of  the 
card,  three  sets  of  markings  may  be  made.  Numbers  are  used 
to  indicate  the  condition  of  the  investing  tissues,  letters  to  indi- 
cate the  condition  of  pulps,  and  symbols  for  decays  and  opera- 
tive procedures.  These  provide  a  definite  plan  of  recording 
practically  all  conditions  ordinarily  met  with  in  dental  practice. 
The  numbers  indicating  the  inflammations  of  the  investing  tis- 
sues are  particularly  important,  as  the  area  may  not  only  be 
definitely  located  but  the  cause  may  also  be  indicated.  If  the 
operator  has  before  him  a  chart  containing  these  numbers  he 
will  very  soon  become  familiar  with  most  of  them.  The  use  of 
the  various  numbers,  letters  and  symbols  is  fully  explained  in 
the  descriptions  of  the  accompanying  illustrations.  (See  Fig- 
ures 502  to  507.) 

The  use  of  the  card.  When  a  patient  presents  for  exam- 
ination, the  name,  address,  and  possibly  the  name  of  the  person 

*  Keeping  of  Dental  Records  and  Accounts.     Northwestern  Dental  Jour- 
nal, Vol.  2,  p.  15. 

t  Preventive  Treatment  of   Peridental   Disease,    Dental    Review,   Vol.   20, 
1912,  p.  801. 


458  SPECI^VX.   DENTAL   PATHOLOGY. 

who  referred  the  imtient,  are  entered.  Then  as  the  examination 
proceeds,  the  dentist,  with  the  chart  before  him  as  a  guide  until 
he  becomes  familiar  with  it,  may  mention  the  conditions  found, 
while  the  assistant  records  them.  For  example,  he  may  direct 
her  to  enter  under  "General  Conditions"  the  number  62  (see 
Table  No.  2)  which  would  indicate  that  the  patient's  care  of  the 
mouth  was  generally  poor.  It  is  not  necessary  that  the  patient 
know  the  meaning  of  the  number.  Or,  if  there  should  be  a  gen- 
eral recession  of  the  gingivae,  without  apparent  cause,  the  num- 
])er  17  would  bo  entered  under  ''General  Conditions."  During 
the  more  critical  examination  of  each  jaw,  deposits  of  salivary 
calculus  will  frequently  be  found  on  the  lingual  surfaces  of  the 
six  lower  front  teeth,  and  the  assistant  would  be  asked  to  mark 
the  figure  18  in  the  projDer  places ;  or  if  deposits  are  present  on 
the  majority  of  the  teeth,  the  figure  18  may  be  entered  under 
general  conditions.  If  there  is  an  inflamed  septal  tissue,  the  num- 
ber indicating  both  this  fact  and  the  cause  should  be  entered  in 
the  pro])er  place.  Detachments  of  the  peridental  membrane  may 
be  definitely  recorded,  with  the  depth  of  the  pockets.  Deposits  of 
serumal  calculus  should  be  noted.  In  this  way  every  item  in 
the  examination  is  recorded.  Occasionally  something  will  be 
observed  that  can  not  be  recorded  by  any  of  the  numbers,  letters 
or  symbols  in  the  tables,  and  it  will  be  necessary  to  make  a  brief 
written  memorandum  on  the  card. 

It  is  desirable  to  enter  the  patient's  age.  Some  patients 
are  inclined  to  resent  being  asked  their  age  by  the  dentist,  and 
as  it  is  not  important  that  the  exact  age  be  recorded,  I  generally 
guess  at  the  age  for  adults,  and  make  the  entry  as  M36  or  F28, 
indicating  the  sex  and  age.  This  is  entered  in  the  lower  left 
corner,  although  the  word  age  does  not  appear  on  the  card. 
Patients  will  often  look  over  these  cards  and  they  will  not  under- 
stand the  entry,  so  there  will  be  no  criticism  if  the  dentist  has 
guessed  too  high. 

Fillings  and  other  operations  to  be  performed  are  entered 
as  indicated  in  the  illustrations.  If  there  is  a  discussion  of  fees, 
a  record  should  be  made,  on  the  reverse  side  of  the  card,  if  neces- 
sary, which  will  specify  the  operations  covered  by  the  fee  men- 
tioned, so  that  there  will  be  no  misunderstanding  later  on. 

The  card  should  be  placed  in  an  alphabetical  file  and  on  the 
occasion  of  each  subsequent  appointment,  it  should  be  laid  out 
on  the  operating  tray,  so  that  the  dentist  may  see  at  a  glance 
what  is  to  be  done.     The  card  will  be  an  aid  in  recording  the 


EXAMINATIONS   OF    THE    MOUTH.  459 

operations  performed,  and  if  each  is  checked  on  the  examination 
card  as  it  is  entered  on  the  patient's  record,  the  card  will,  on 
each  return  of  the  patient,  show  the  operations  which  have  been 
completed,  and  those  which  are  yet  to  be  performed. 

When  the  series  of  operations  is  completed,  the  card  is  again 
placed  in  the  file  for  future  reference.  On  the  occasion  of  the 
next  examination  of  the  same  patient,  six  months  or  a  year  later, 
a  review  of  the  case  should  be  made.  Locations  in  which  the 
gingivae  were  inflamed  at  the  time  of  the  previous  examination 
should  receive  particular  attention.  If  there  were  deposits  of 
serumal  calculus  about  certain  teeth,  it  will  be  important  to  know 
if  new  deposits  have  occurred.  If  certain  positions  were  marked 
for  deposits  of  salivary  calculus  or  for  lack  of  cleanliness,  it 
will  be  interesting  to  note  whether  or  not  the  patient's  care  has 
improved.  If  so,  a  statement  to  that  effect  should  be  made;  if 
not,  new  directions  and  additional  warnings  should  be  given  in 
the  effort  to  secure  improvement  in  the  future.  If  contacts  have 
been  built  out,  or  other  operations  performed  to  cure  areas  of 
gingivitis,  the  subsequent  examination  will  demonstrate  whether 
or  not  these  were  successful.  In  this  connection  it  is  important 
that  the  original  memorandum  shows  whether  or  not  there  was 
at  that  time  a  pocket,  because  it  will  be  found  that  contacts  will 
not  remain  tight  if  there  has  been  much  detachment  of  the  trans- 
septal  fibers,  the  chief  function  of  which  is  to  hold  the  teeth  in 
close  contact. 

Such  a  systematic  plan  of  handling  cases  and  checking  them 
can  not  fail  to  be  effective  in  improving  the  service  of  the 
dentist  and  in  bringing  patients  to  a  better  appreciation  of  the 
value  of  this  service,  to  the  end  that  they  will  themselves  become 
more  earnest  in  the  care  of  their  mouths. 


400  SPECIAL    DET^TAL   PATHOLOGY. 


APPENDIX. 

A  MACHINE  FOR  GRINDING  MICROSCOPIC 

SPECIMENS. 

ILLUSTRATIONS:    FIGURES  508  518. 

IN  connectioii  with  my  studies  of  the  pathology  of  the  hard 
tissues  of  the  teeth  and  of  other  hard  substances,  such  as 
deposits  of  calculus,  bone,  etc.,  I  found  it  necessary  to  have  a 
machine  with  which  an  almost  unlimited  quantity  of  hard  mate- 
rial could  be  ground  for  microscopic  study,  with  the  greatest 
possible  degree  of  accuracy.  The  old  method  of  cutting  a  sec- 
tion from  a  tooth  and  grinding  it  down  by  hand  to  microscopic 
thinness  was  out  of  all  question,  as  I  required  hundreds  of  such 
sections.  A  machine  for  this  purpose  was  not  available ;  I  there- 
fore designed  one  and  had  it  built  to  order.  This  at  once  enabled 
me  to  have  prepared  without  delay  and  with  little  effort  on  the 
part  of  my  laboratory  assistant,  the  finest  grindings  of  the  hard 
tissues,  ready  for  microscopic  examination.  Without  such  a, 
machine  it  would  have  been  impossible  to  have  prepared  such 
sections  as  are  shown  in  a  number  of  the  illustrations.  For 
extimple.  Figures  163  arid  259  show  beautiful  photomicrographs 
of  sections  of  roots,  one  with  a  deposit  of  salivary  calculus,  the 
other  with  a  deposit  of  serumal  calculus  attached.  These  sec- 
tions were  ground  to  one-half  of  one  thousand  of  an  inch,  by 
placing  a  thick  slice  of  the  material  in  the  machine  and  adjusting 
the  micrometer  gauge  for  the  thinness  desired,  and  turning  on 
the  electric  current.  The  machine  stopped  automatically  when 
the  section  was  ground  according  to  the  adjustment  of  the  gauge. 

The  machine  has  two  mechanisms,  one  for  slicing  the  mate- 
rial so  that  the  sections  may  be  mounted  on  a  disk,  the  other  for 
grinding  sections  so  mounted  to  microscopic  thinness.  It  is  with 
the  belief  that  quite  a  few  memliers  of  the  profession  will  be 
interested  that  I  present  a  description  of  the  machine,  with  a 
number  of  illustrations,  in  this  book. 

The  basis  of  this  machine  is  the  larger  watchmaker's  lathe, 
known  as  No.  2.     It  must  swing  4  inches,  the  length  of  the  bed 


GRINDING    MICROSCOPIC    SPECIMENS.  461 

must  be  12  inches,  and  be  al)solutely  solid.  A  test  should  be 
made  of  the  alignment  of  the  lathe  head  to  see  that  this  is  exact. 
If  there  is  any  inaccuracy,  another  lathe  should  be  selected.  The 
power  should  consist  of  one-fourth  horse-power  motor,  of  the 
type  made  for  the  dental  laboratory  bench.  This  power  should 
be  transmitted  to  the  lathe  through  an  overhead  shaft  of  a  length 
that  will  give  good  room  to  operate  the  lathe  without  the  motor 
being  in  the  way,  as  shown  in  Figures  510  and  511. 

THE    SLICING    MECHANISM. 

This  is  an  arrangement  for  slicing  very  hard  substances 
which  can  not  be  cut  with  the  ordinary  steel  saw  —  such  as  the 
enamel  of  teeth,  silicified  fossils,  rocks,  etc.  (See  Figures  508 
and  509.)  This  consists  of  an  aluminum  disk  fitted  to  the  lathe 
head,  and  surrounded  by  a  special  form  of  spatter  guard  that 
admits  of  the  use  of  the  periphery  for  cutting,  and  an  object- 
holder  fixed  upon  the  slide  rest  of  the  lathe.  The  object-holder 
consists  of  a  clamp  that  grasps  a  brass  tube  slotted  at  the  free 
end,  in  which  teeth  or  other  objects  may  be  made  fast  with 
plaster  of  Paris  or  sealing-wax  for  slicing.  Or  in  place  of  this 
a  brass  mandrel,  upon  the  end  of  which  there  is  a  threaded  nipple 
by  which  any  of  the  grinding  disks  may  be  attached.  These  are 
fixed  in  the  position  of  the  ordinary  tool  post,  and  may  be  swung 
horizontally  to  any  possible  position  in  relation  to  the  aluminum 
disk.  An  object  can  therefore  be  so  placed  on  the  disk  as  to  be 
cut  in  any  direction  desired.  Usually  these  are  fixed  upon  the 
disk  with  sealing-wax.  In  using  the  aluminum  disk  it  is  fed 
with  carborundum  powder  suspended  in  soapy  water  to  give  it 
some  stickiness.  This  is  applied  with  a  brush  by  hand,  and  is 
kept  going  so  constantly  as  to  prevent  the  disk  from  running 
dry.  The  ordinary  aluminum  plate,  of  twenty-four  to  thirty 
gauge,  may  be  used  for  making  these.  They  are  first  cut  in 
circles  by  hand,  as  large  as  the  lathe  will  swing  (4  inches),  and 
then  are  cut  down  to  3'/.  inches  with  a  tool  in  the  slide  rest. 
These  are  quickly  made  when  wanted.  They  wear  out  rapidly, 
and  yet  one  of  them  will  do  much  cutting  of  very  hard  sub- 
stances, and  do  it  accurately  and  delicately.  Rings  may  readily 
be  cut  from  the  ordinary  glass  test-tubes  witliout  special  danger 
of  breaking.  The  crown  of  a  molar  tooth  may  be  cut  into  many 
slices;  fossil  teeth,  silicified  fossil  woods,  stones,  etc.,  may 
readily  be  sliced  as  thin  as  they  can  be  handled  in  the  after-work 
of  preparation. 


462  SPECIAL   DENTAL   PATHOLOGY, 

THE    GRINDING    APPARATUS. 

The  grinding  apparatus,  shown  in  Figures  512  and  513,  is 
built  upon  a  base  fitted  to  the  lathe  bed  in  the  same  way  as  the 
lathe  head,  or  tailpiece.  It  has  one  main  shaft  parallel  with  the 
lathe  bed,  in  good  and  sufficient  bearings  to  maintain  accuracy 
of  alignment  and  perfect  steadiness  for  long  continued  usage. 
This  shaft  moves  freely  lengthwise,  or  backward  and  forward, 
while  turning  slowly  in  its  bearings.  On  the  end  of  this  shaft 
next  to  the  lathe  head  —  the  forward  end  —  there  is  a  larger 
portion,  or  ring,  and  this  end  terminates  in  a  threaded  nipple, 
upon  which  the  removable  grinding  disks  are  screwed  firmly 
against  the  face  of  this  larger  ring,  to  secure  accuracy  of  adjust- 
ment.    The  use  of  these  disks  will  be  more  fully  explained  later. 

The  micrometer  adjustment  is  to  the  right  of  the  housing 
for  the  shaft.  (See  Figure  513.)  A  piece  is  embedded  on  the 
lathe  bed,  but  left  free  to  slide  back  and  forth  in  the  length  of  the 
shaft ;  this  reaches  nearly  to  the  housing  of  the  principal  shaft, 
when  it  is  pushed  through  as  far  as  it  will  go.  The  shaft  has  a 
bearing  in  the  front  end  and  back  end  of  this  cylinder,  upon 
which  the  part  moves  back  and  forth  with  the  shaft.  The  shaft 
is  connected  by  a  worm  gear  to  a  pulley  wheel  back  of  the  shaft, 
which  is  actuated  by  a  belt  on  the  middle  pulley  on  the  overhead 
shaft.  (See  Figures  511  and  514.)  This  allows  the  piece  to 
move  backward  or  forward  at  will  through  its  bearings  and 
housings,  which  are  attached  to  the  lathe  bed  by  the  thumbscrew 
below.  The  micrometer  is  attached  to  the  front  end  of  the  cylin- 
der, which  is  made  solid  with  the  housing  of  the  wheel  which 
turns  the  shaft.  On  the  front  end  of  this  cylinder  a  nut  is  placed 
upon  screw  threads  which  forms  the  micrometer.  This  nut  does 
not  turn  with  the  shaft,  and  the  scale  is  always  before  the  eyes 
of  the  operator.  This  nut,  with  the  graduations  cut  in  it,  is  to  the 
left  of  the  worm  gear  near  the  right  end  of  the  shaft  in  Figure 
513.  The  movable  nut  has  forty  threads  to  the  inch.  Moving 
the  nut  through  one  revolution  gives  twenty-five  one-thousandths 
of  an  inch,  and  this  gradation  is  placed  upon  it.  The  gradation 
of  the  disk  is  on  the  same  principle  as  that  on  the  screw  calipers 
used  by  machinists  for  fine  measurements  —  one-thousandth  of 
an  inch  —  but  as  this  disk  is  1%  inches  in  diameter,  the  grad- 
uations of  thousandths  are  so  wide  that  one-quarter  of  one- 
thousandth  may  readily  be  used.  It  differs  in  plan,  in  that  both 
the  graduation  and  the  parallel  lines  are  placed  upon  this  disk. 
On  the  machinist's  micrometer  the  lines  are  placed  on  the  shaft 


GRINDING    MICROSCOPIC    SPECIMENS.  463 

and  the  graduations  on  the  nut.  The  graduation  is  read  from 
the  side  of  the  finger  on  the  movable  nut,  and  the  lines  are  read 
from  its  end. 

Turning  the  screw  of  the  micrometer  backward  allows  the 
shaft  to  move  farther  forward  toward  the  grinding-stone. 
Moving  it  forward  draws  the  shaft  back  from  the  grinding-stone. 
The  measurement  of  this  movement  constitutes  the  basis  of  the 
action  of  the  micrometer.  In  action  the  front  part  of  the 
micrometer  engages  with  a  lever  from  a  bar  gliding  in  the  auto- 
matic cut-off,  and  this  automatic  cut-off  throws  a  switch  which 
turns  off  the  current  of  electricity  at  a  certain  point  and  stops 
the  movement  of  the  machine.  (See  Figures  515  and  516.)  The 
adjustment  of  the  micrometer  is  so  made  that  this  cut-off  will  be 
thrown  and  stop  the  machine  at  the  measurement  determined 
upon  for  the  finishing  of  the  grinding,  and  for  which  the  microm- 
eter is  set.  When  this  switch  is  thrown  by  the  forward  move- 
ment of  the  shaft  the  motor  and  the  whole  apparatus  stops. 
At  each  time  the  switch  is  thrown  it  must  be  reset  to  turn  on  the 
current  and  start  the  machine  again.  It  is  a  very  perfect  mi- 
crometer. It  may  be  seen  in  Figui'es  512,  513  and  514  at  the  right 
end  of  the  shaft.    The  adjustment  will  be  given  in  detail  later. 

The  forward  movement  of  the  shaft  when  grinding,  and 
also  the  pressure  exerted  upon  the  stone,  are  furnished  by  a  tail- 
piece placed  behind  it  and  attached  to  the  lathe  bed.  (See 
Figure  512.)  This  has  a  plunger  actuated  by  a  spiral  spring, 
which  pushes  the  shaft  forward  toward  the  stone.  The  amount 
of  pressure  exerted  in  the  grinding  is  controlled  by  the  amount 
of  compression  of  this  spring  in  fixing  the  piece  to  the  lathe  bed. 
It  may  be  much  or  little,  as  desired.  Usually  very  little  pressure 
is  required.  The  further  arrangement  for  finding  this  measure- 
ment will  be  described  later. 

On  the  rear  portion  of  the  graduated  disk,  or  wheel,  a  por- 
tion or  space  is  toothed,  and  connected  with  a  wonn  pinion  or 
threaded  shaft  by  which  the  main  shaft  is  turned  in  its  bearings. 
A  belt  is  attached  over  a  wheel  on  the  end  of  this  worm  shaft, 
and  extends  to  the  middle  wheel,  previously  mentioned,  on  the 
overhead  shaft.  When  this  belt  is  adjusted  and  the  motor 
started,  it  causes  the  main  shaft  in  the  grinding  machine  proper 
to  turn  slowly  on  its  axis,  while  being  pressed  against  the  stone 
by  the  tailpiece.  By  this  arrangement  every  part  of  the  speci- 
men fixed  on  the  grinding  disk  is  brought  successively  against 
every  part  of  the  rapidly  revolving  stone,  and  is  cut  perfectly 
level  in  all  of  its  parts.     (See  Figures  512  and  513.) 


464  SPECIAL   DENTAL   PATHOLOGY. 

The  grinding  disks.  The  grinding  disks  are  of  brass,  accu- 
rately turned  %  inch  thick,  and  1%  inches  in  diameter.  They 
have  a  threaded  hole  Vi  inch  deep  in  the  back  to  fix  them  to  the 
nipple  on  the  forward  end  of  the  shaft  of  the  grinding  machine. 
A  machine  should  have  a  half-dozen  or  more  of  these,  lettered  or 
numbered  on  the  edge,  so  that  records  of  each  may  be  made 
when  measuring  preparatoiy  to  mounting  specimens  for  grind- 
ing. As  the  mounting  of  specimens  on  others  of  these  may 
proceed  while  the  grinding  on  one  is  going  on  (for  the  machine, 
being  automatic,  needs  little  attention),  at  least  six  are  necessary 
for  rapid  work. 

The  machine  may  be  stopped  and  the  disk  removed  from  the 
shaft  by  a  few  backward  turns,  the  progress  of  the  grinding 
examined,  the  disk  returned  for  further  grinding,  etc.,  at  any 
time  during  the  progress  of  the  work.  The  face  of  the  disk, 
which  should  be  perfectly  flat  and  parallel  with  the  face  of  the 
stone,  should  always  be  perfectly  bright,  so  as  to  reflect  light 
through  the  specimen  when  it  becomes  thin.  This  enables  one 
to  judge  very  closely  of  the  thickness  by  the  eye  (after  sufficient 
practice),  which  sometimes  proves  a  valuable  check  on  the  set- 
ting of  the  measurement  in  the  beginning. 

The  point  finder.  This  is  a  piece  of  steel  one-eighth  of  an 
inch  thick,  fitted  to  the  lathe  bed  and  set  against  the  face  of  the 
lathe  head,  and  made  fast  by  a  thumbscrew  passing  through  the 
lathe  bed  from  below.  (See  Figure  513.)  It  has  a  strong  arm 
which  passes  around  other  fixtures  between  the  lathe  head  and 
the  forward  end  of  the  base  of  the  grinding  machine.  It  is  pro- 
vided with  a  set-screw,  by  which  a  range  of  variation  can  be 
made  in  the  distance  of  the  forward  end  of  the  frame  of  the 
grinding  machine  from  the  lathe  head.  When  this  is  in  place 
and  the  measurement  of  a  disk  has  been  made  and  recorded  for 
the  grinding  of  a  specimen  to  a  specified  thickness,  the  machine 
may  be  taken  to  pieces  and  set  up  again  and  the  grinding  pro- 
ceed without  fear  of  disturbing  the  measurement,  so  long  as  the 
set-screw  in  the  point  finder  is  not  moved.  It  is  often  necessary 
during  grinding  to  loosen  the  grinding  machine  from  the  lathe 
bed,  slide  it  back  to  adjust  something,  to  remove  disks  for  exam- 
ination of  the  progress  of  the  work,  etc.  This  point  finder,  by 
preserving  the  distance  between  the  lathe  head  and  the  grinding 
machine,  enables  one  to  do  this  at  will,  and  again  find  his  exact 
l)oint  of  measurement  simply  by  sliding  the  frame  of  the  grind- 
ing machine  forward  against  the  set-screw  of  the  point  finder. 


GRINDING    MICROSCOPIC    SPECIMENS.  465 

This  little  device  seems  absolutely  necessary  to  the  highest  use- 
fulness of  the  machine. 

Lap  wheels.  I  began  my  work  of  grinding  specimens  by 
the  use  of  lap  wheels,  but  soon  discarded  them  because  they  were 
dirty.  They  cut  much  faster  than  stones,  however,  and  may  be 
used  for  the  bulk  of  the  work  when  much  grinding  of  very  hard 
material  is  to  be  done.  They  are  not  necessary  in  grinding 
teeth,  bone,  etc.,  but  in  grinding  the  harder  fossils,  especially 
those  impregnated  with  the  silicates,  and  in  some  geological 
work,  they  become  necessary. 

The  best  lap  wheel  I  have  used  is  an  aluminum  wheel.  Brass 
or  iron  will  do  the  work,  but  aluminum  holds  the  grit  better,  cuts 
with  lighter  pressure,  and  does  the  work  more  quickly.  In  using 
these  I  have  fed  them  continuously  by  hand  with  carborundum 
powder  in  soapy  water,  using  a  brush. 

Grinding-stones.  Any  one  who  is  doing  much  grinding 
should  have  a  good  supply  of  stones.  I  have  a  pair  of  carborun- 
dum wheels,  a  pair  of  emery  wheels,  a  pair  of  India  oil-stones, 
and  a  pair  of  Arkansas  stones.  In  each  of  these  pairs  one  is  fine 
and  the  other  coarser  grit.  Every  stone  is  dressed  to  a  perfect 
face  on  the  lathe  head  where  it  is  to  do  its  work,  with  a  black 
diamond  held  in  the  slide  rest. 

These  stones,  when  put  in  good  shape,  seem  capable  of  doing 
an  unlimited  amount  of  work.  The  conditions  of  the  grinding 
jjrevent  them  from  getting  out  of  true.  All  that  seems  neces- 
sary is  to  roughen  them  a  bit  with  a  picking  wheel  when  they 
become  too  smooth  to  cut  well.  For  this  purpose  a  much  smaller 
picking  tool  than  the  smallest  sold  for  the  general  mechanical 
uses  seems  desirable.  This  picking  wheel  has  sharp  teeth  of  the 
hardest  steel  possible  on  its  periphery.  It  is  held  in  a  handle 
in  such  form  that  the  wheel  is  free  to  turn.  In  use  it  is  held 
against  the  rapidly  rotating  stone  and  slowly  passed  over  its 
entire  surface.  It  may  be  held  in  the  hand,  aided  by  a  tool  rest, 
or  may  be  arranged  for  use  in  the  slide  rest,  which  is  the  better 
form  for  this  work. 

Watering  the  stones.  In  grinding,  the  stones  are  kept  wet 
in  running  ice-water.  A  balsam  that  is  too  soft  to  hold  a  speci- 
men for  grinding  in  water  at  room  temperature  will  hold  it 
perfectly  in  ice-water,  because  it  is  much  harder  when  cold.  For 
this  purpose,  a  bucket  or  a  large  rubber  bag  is  hung  on  the  frame 
which  holds  the  overhead  shaft,  and  is  filled  with  bits  of  ice  and 
then  filled  with  water.  Both  the  ice  and  the  water  must  be  clean, 
for  the  opening  in  the  tube  where  it  passes  the  valve  which  regu- 


466  SPECIAL    DENTAL   PATHOLOGY. 

lates  the  flow  is  very  small,  and  a  small  particle  of  dirt  might 
stop  the  flow.  In  this  case  the  specimen  being  ground  would  be 
burned  instantly.  An  ordinary  rubber  tube  conducts  the  water, 
and  is  connected  with  a  metal  tube  having  a  brush  attached  to 
the  other  end.  This  tube  is  mounted  on  a  stand  and  the  brush 
may  be  placed  in  any  desired  position  to  deliver  the  water  to  the 
stone.  This  metallic  tube  is  provided  with  a  valve  for  the  regu- 
lation of  the  flow.  The  brush  is  made  upon  a  short  tube  fitted 
into  the  end  of  the  metal  tube.  To  make  this  brush,  the  plain 
part  of  the  small  brass  tube  is  first  covered  with  thick  shellac 
dissolved  in  absolute  alcohol.  A  layer  of  the  bristles  are  then 
placed  around  it  and  wrapped  tightly  with  a  fine,  strong  thread. 
More  shellac  is  applied  and  another  layer  of  bristles  added. 
This  is  continued  until  the  brush  is  large  enough.  Then  it  is 
wrapped  thoroughly  with  a  cord  in  shellac,  allowed  to  dry,  and 
then  trimmed.  Two  of  these  have  served  for  six  years  of  fairly 
hard  usage. 

Waste  water.  A  spatter  guard  is  made  by  bending  a  five- 
eighth-inch  round  brass  tube  into  a  circle,  the  inner  diameter  of 
which  is  the  size  of  the  stones  used,  and  brazing  the  ends  solidly 
together.  This  is  fixed  in  the  lathe  and  one-fourth  of  its  inner 
circular  diameter  is  turned  away.  The  grinding-stones  will  go 
inside  this.  This  piece  is  provided  with  a  foot  and  hollow  post 
and  fitted  to  the  lathe  bed  with,  a  washer  and  nut,  the  same  as 
other  pieces  are  attached.  This  catches  all  waste  water  and 
through  a  rubber  tube  attached  to  the  end  of  its  hollow  post 
under  the  lathe  bed  delivers  it  into  a  convenient  receptacle.  This 
prevents  all  of  the  spattering  of  water  which  would  otherwise  be 
thrown  from  a  rapidly  revolving  wheel.  If  it  should  be  inclined 
to  run  over  when  a  very  full  stream  is  wanted,  a  piece  of  rubber 
dam  may  be  stretched  over  the  foot  and  pulled  to  its  upper  end. 
This  may  be  caught  under  the  guard  in  fastening  it  to  the  lathe 
bed,  and  will  deliver  any  overflow  into  a  receptacle  placed  to 
receive  it.     In  this  way  nothing  is  wet  or  spattered  with  water. 

Preparation  of  material. 

In  the  preparation  of  material,  such  as  teeth,  bone,  etc.,  in 
histological  work  of  ordinary  delicacy,  the  specimen  is  first 
ground  flat  on  one  side  by  hand  on  a  rough  stone  4  inches  in 
diameter,  on  the  motor,  and  finished  perfectly  flat  on  one  of  the 
finer  stones  on  the  lathe  head.  The  piece  is  then  washed  clean 
and  placed  in  absolute  alcohol  for  a  sufficient  time  to  remove  all 
traces  of  water,  or,  when  cracking  or  injury  from  shrinkage  is 


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Figs.  508  and  509.  I.nthc  witli  niccluinisin  for  sliciiifi  very  liard  inattM-ial. 
Figure  508  is  the  more  ordinary  vit  w  of  the  niai'irmc  witii  tlw  slitl.-  n-st  and  objet't 
liolder  in  position.  In  Figiuv  509  tlic  latlic  is  tiirm-d  alxnit  to  ;iiv('  a  ln-tter  view  of 
the  slide  rest,  object  ludder,  sjiatter  guard,  and  aluniinnin  disk.  .V  general  view, 
sliowing  the  arrangement  for  1  ri-nsinission  of  jtowcr  from  the  motor  is  sliown  in 
Figure  511.  In  Figure  509  the  slotted  tube  ii-^.d  to  lioM  tlic  object  iicing  eut  may  lie 
seen  elose  to  the  eutting  disk.  Water  from  a  rubb.r  liag  Imng  above  (See  Figure 
51  J)  is  eondueted  through  a  rublier  tubing  to  the  aii.justable  metal  tube  on  whieh  the 
brush  is  mounted.  The  disk  used  for  cutting  is  surrounded  by  a  sjiatter  guard  which 
is  o]ien  for  a  space  at  oiu'  side  so  lh:it  the  periphery  of  the  ilisk  may  be  used  in 
oitting.  This  guard  gatiu-rs  ail  watei-  ami  grit,  and  delivers  it  into  a  |ian  below 
through  a  hollow  post  to  whiidi  a  tube  is  connected.  Wlien  doing  this  kind  of  work  all 
of  the  bearings  of  the  machine  should  be  (-arefully  swaddled  (wrapped)  to  keep  them 
safe  from   intrusion  of  grit. 


*42 


m\ 

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^H  I 

w 

^^^^^^^^^^^^^^^^^^^^^^l&  ;  ^  '''•^^^iJii^^LBa                 ^^^^U 

'  m 

^^                         ^^  ^^^^^^K™ ^^all  B^^^^H^^^:::^ 

^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^H 

^^^^^^^^^^^^^^^H 

Fig.  i310. 


Fig.    510.      General    view   of   the    jirindiiiy    inacliirio    in    operation.      It    is    shown 
better  in  Figure  511  and  is  there  described. 


Fig.  511. 


is  a  <'oi)V  —  rovers f  Hi"   imiIIcv  on  the  lath.- 

Uu'ConUT  of  tlu>  overhca.l  shaft   .s   f,,,-  tl,.'   pu,, 1    ,ot:,t,>,^'  H,.  .hsk  ..u-.-v.n^  tl..' 

six'ciiiu'ns  while  they  ai-e  Ixmuk'  }iro,,,i,l. 

Water   is   ,hliv.n',|    ,„   tl„.   uri-nlnm   st,,,,.'    In.,,,    ;,    r„l,l..r    la;;   or    Imeket    lu.nK'   on 
.,    nil,l..r  Mil."   1,,  tl,r  „i,M;,l   t„i,r  oi,  :,   „,oval.le  stan.l,  which 


the  fnuno  above,  tliroii^; 

iiviv  he  so  Diaced  as  to  l)rmu  me  i,,,isii  :ii    ii->  ,  ,,,.  .i^ - ■■       ■■•   ,  ,, 

3.  are  I'.tter  seen  in   Fi«,nv  -,V2.     Tl„.  w:,,-,-  ,s  eonveye.!  fron,  the  l:..he  l-v  another 
tul)e    (n<->t    shown    in   this   ilh,st  ,:,t  ion )    \\hi,'l,    n,av   he  se.M,    in    !•  imu,-- 


ay  be  so  place,!  as  to  brin^  the  l„„sh  ;,t    its  ,„,1  n-ainst   Ih..  sto.w.      'I'his  stan.l  an,l 


Fig.  r,]2. 


Figs.  512  axd  ')\''>.  Tlu'  latlu-  with  the  grinding  machine  mounted  upon  it  in 
position  for  Avovk.  On  the  U^ft  next  to  the  lathe  head  is  the  grinding  stone  sur- 
rounded by  the  sputter  guard,  which  gathers  all  of  the  water  from  the  wheel  and 
delivers  it  through  its  hollow  post  into  a  rubber  tube  below-  the  lathe  bed,  which  con- 
veys it  to  a  conveniently  placed  receptacle.  The  water  comes  from  a  rubber  bag  or 
bucket  hung  on  the  overhead  frame  (See  Figure  511)  through  a  rubber  tube  to  the 
metal  tulje  mounted  on  a  movable  stand  so  that  the  brush  through  which  it  passes 
may  be  ])laced  against  the  stone.  The  grinding  machine  proper  is  secured  to  the 
lathe  bed  by  tlie  larger  tlnnub-screv,'  seen  lielow.  The  point-finder  is  seen  at  the  foot 
of  the  spatter  guanl,  and  is  secured  bv  the  iiiidijli'  thumb-screw  seen  below  the  lathe 
bed. 

The  shaft  of  the  grinding  machine  (6  inches  long)  runs  through  its  whole  length, 
but  is  completely  covered  in  by  its  housings  to  protect  its  bearings  from  grit,  except 
at  its  forward  end  (next  to  the  grinding  stone).  This  part  is  protected  by  a  swaddle 
held  by  a  ring,  which  kee))s  the  Avorking  bearing  clean.  On  this  end  the  grinding 
ilisk  is  seen  almost  touching  the  st.me.  The  micrometer  surrounds  the  other  end  of 
the  shaft,  but  does  not  touch  it.  It  is  connected  with  the  back  end  of  the  machine, 
which  is  freely  movable  backward  and  forward,  carrying  the  shaft  with  it.  In  the 
iiaek  part  of  this  is  a  toothed  wheel  made  fast  to  the  shaft.  This  is  actuated  by  a 
worm  drive  on  the  shaft  of  a  pulley  wheel  driven  by  the  middle  one  of  the  belts 
descending  from  the  overhead  shaft  in  Figure  511,  the  right-hand  belt  in  Figure  512. 
This  belt  passes  o\er  a  whecd,  wiuch  may  be  seen  in  Figures  514,  515  and  516. 
Pressure  for  the  grinding  is  supplied  by  a  plunger  actuated  liy  a  spiral  s|)ring  seen 
at  the  extreme  right  hand  in  Figure  512. 


rui.  .jio. 


Fig.  513.      'I'lic  ;iriiiiliiit,r  sidiii'  •Hid  •<li:it'l    nt'  llir  y;riiiiliii;,'  m;n.'liilic. 
Fur  (k'script  inn,  sec  nppnsitc  l>:iji[('. 


Fig.  514. 


^i'^*'-  ^^'^-  ^^'^-  Vipw  from  above  of  grinding  apparatus  with  the  electric  cut-oflf. 
^i*" •-■''' The  hoiisirtg,  for  .  the  electric  cut-off  is  above  the  shaft  in  the  illustration.  The 
button  above  this  hou.sing  (on  the  back  side  of  the  uiacliine)  is  set  with  the  fingers 
to  start  tlie  machine  after  it  has  automatically  liroken  the  current  and  stopped  the 
uiachinc.  The  pulley  wheel  to  the  right  of  the  illustration  is  connected  with  the 
middlf  puih'V  on  the  oxerhead  shaft.  This  pulley  shaft  engages  the  worm  drive  on  the 
grinding  shaft,  causing  it  In  revolve.  To  the  left  end  of  this  shaft  is  the  grinding 
disk  on  which  the  specimens  to  be  ground  are  attached.  The  action  of  this  in 
relation  to  the  stone  is  explaine<l  in  the  text.  The  mechanism  of  the  electric  cut-off  is 
shown  in  Figures  51.5  and  oKi. 

The  return  current  from  the  motor  is  diverted  to  [)ass  thrcnigh  this  cut-off  by 
plugging  into  the  two  large  holes  to  the  left  side  of  the  mechanism.  The  respective 
poles  are  connected  through  the  mechanism  with  the  two  plates  which  are  situated 
l)elund  the  two  bars,  the  ends  of  which  overlap  near  the  center  of  the  mechanism  in 
Figure  515.  The  ])late  back  of  the  left  or  fixed  bar  is  seen  better  in  Figure  516. 
In  this  illustration,  the  other  plate  has  snapped  down  with  the  other  bar.  These  two 
bars  are  of  hardened  steel,  with  accurately  ground  chisel  edges.  There  can  be  no  arc 
(if  flic  electric  current  between  these  bar  ends,  as  the  contact  of  the  |ilates,  which  arc 
wiiliT,  is  not  broken  until  after  the  bars  have  separated. 

As  the  shaft  of  the  grinding  a])paratus  is  moved  toward  the  stone  by  the  spring 
of  the  tailpiece,  one  of  the  steel  bars  iiio\es  with  the  shaft,  and  when  the  movement 
has  coidinued  to  the  i>oint  det<  rmiiu'd  by  the  adjustnuMit  of  th(>  micrometer,  the  chisel 
edge  of  the  movable  bar  will  pass  the  edge  of  the  other  bar,  and  a  spring  causes  the 
bar  to  the  right  in  the  illustrations  to  snap  down,  carrying  the  contact  plate  with  it, 
thus  breaking  the  current  and  stopping  both  the  grinding  stone  and  the  shaft.  The 
spiral  spring  shows  best  in  Figure  515.  The  switch  may  be  reset  by  the  knob  on  the 
back  of  the   mechanism. 

.Inst  t(i  tiic  left  nf  this  sjiiral  spring  and  in  line  witii  it  is  a  flat  s[)i-ing  attached 
at  its  left  ciKJ,  wliicli  iicars  against  ii  plate  in  under  the  spiral  si>ring.  This  delivers 
the  current  tinm  tlie  lower  socket  to  the  sliding  jiart.  maintaining  a  i)ressure  contact. 
The  large  screw  below  in  both  illustrations  is  for  the  purpose  of  attaching  the  shaft 
to  the  lathe  bed. 


Fw.  515. 


Pk;.  51(1 


FiriS.  515  AND  5t().  N'lews  f'nim  tlic  lnnk  nf  tlir  ;;riii(|iiit,r  ai.iciriitiis,  dctaflii'.l 
from  the  latlie,  ami  with  tlio  lioiisiiifj  removed  to  sliow  I  lie  elastie  autumatie  cut-otT. 
Figure  515  shows  tlie  bars  set  so  tliat  tiie  rnrreiit  is  on;  Figure  51()  slvows  one  bar 
dropped,  the  cnircnt  liiinir  diseoimecteil.  The  adjustment  of  the  mierometer  is  so 
made  that  this  ciil  nW  will  he  thrown  and  stop  the  maehinr  at  the  measviremeut 
determini'.l   np<>n    for   linishing  tlic  grin. ling.     Src  dcseript ion   nnder    Kignre  514. 


Fjg.  517. 


Fig.  518. 


Figs.  :>\  ,  and  ^.is.  I  1„.  s|,i.lrr  witi,  a  uriudin^  ,lisk  upm,  it  m.uI  a  spe.-iiiien  laid 
and  secured  h.v  l.e.it  n,.s  .-all..!  •■  do^.s."  When  tl.es,.  do^s  are  placed  and  pressed 
uown  through  the  holes  m  the  disk  of  the  spi.ler.  they  iu.ld  fast.  With  a  little  pres- 
sure of  the  finfxer  outward  on  the  en.l  of  th<.  rod  h.^jow  tlie  disk  of  the  snider  the 
do;r  slips  MP  and   is  loose.     The  disk  of  the  spi,l,T  is  tiiir,.  inrlies   in   diameter        ' 


GRINDING    MICKOSCOPIC    SPECIMENS.  467 

not  feared,  it  may  be  dried  in  the  warming  box.  Then  when 
dried  and  warmed  to  about  120°  P.,  it  is  ready  to  mount  with 
balsam  on  the  grinding  disk. 

Management  of  balsam.  I  suppose  the  management  of 
balsam  will  always  be  a  difficult  problem  with  many  persons. 
Many,  however,  learn  it  quickly.  One  may  take  the  dry  balsam 
and  dissolve  it  in  xylol,  and  filter  it  at  a  high  temperature,  say 
110°  F.  or  120°  F.  Or  one  may  use  the  prepared  balsam  for 
microscopic  mountings.  In  either  case  it  must  be  evaporated 
until  stiff  enough  so  that  it  will  move  rather  sluggishly  at 
110°  F.,  but  will  be  fluid  at  120°  F.  or  130°  F. 

Spidees  and  dogs.  Another  bit  of  apparatus  is  necessary. 
A  circular  piece  of  steel  made  flat  on  the  upper  surface  is 
mounted  on  three  legs  li/o  to  2  inches  high.  The  steel  disk 
should  have  two  rows  of  holes  around  its  periphery,  the  one  row 
%  inch  inside  the  other.  A  hard  rolled  tool,  steel  wire,  or  rod 
3/32  inch  in  diameter,  should  exactly  fit  these  holes.  These  rods 
should  now  be  bent  at  right  angles  with  a  short  nib  on  the  end, 
bent  again  at  right  angles,  so  that  the  nib  will  point  downward 
when  the  free  end  of  the  rod  is  set  into  one  of  the  holes.  The 
length  between  these  two  angles  should  vary  from  %  to  IVo 
inches  in  three  dozen  or  more  pieces  which  should  be  prepared. 
The  end  which  goes  in  the  holes  should  be  cut  so  that  it  will  not 
quite  reach  the  surface  of  the  table  when  dropped  into  the  holes 
with  the  end  of  the  nib  on  the  surface  of  the  circular  plate. 
These  rods  are  called  *'dogs."     (See  Figures  517  and  518.) 

With  this  arrangement  a  warming  box  having  a  thermostat 
to  maintain  an  even  temperature,  sufficiently  high  to  soften  the 
stiff  balsam,  is  used.  The  specimen,  the  balsam,  the  grinding 
disk,  and  the  "spider"  are  placed  inside,  and  allowed  to  rest 
until  they  have  reached  the  temperature  desired.  Then,  work- 
ing quickly,  a  sufficient  amount  of  balsam  is  placed  on  the  grind- 
ing disk,  and  the  specimen  laid  on  it.  This  should  be  pressed 
down  until  it  is  seen  that  all  space  under  it  is  filled  with  balsam, 
but  little  excess  should  be  used.  It  is  well  if  this  rest  so  in  the 
warming  box  for  ten  or  fifteen  minutes  for  the  balsam  to  soak 
well  into  the  specimen.  Then  the  grinding  disk,  with  the  speci- 
mens, should  be  laid  on  the  spider  and  one  of  the  dogs  dropped 
into  one  of  the  holes  in  the  steel  plate,  which  will  bring  its  nib 
on  to  a  part  of  the  specimen  chosen.  Then  another,  and  still 
another,  should  be  placed,  each  with  its  nib  on  a  different  part 
of  the  specimen,  so  that  every  part  of  it  may  be  pressed  flat  on 
the  disk.     Each  in  turn  is  then  pressed  down  a  little,  until  all 


468  SPECIAL    DENTAL   PATHOLOGY. 

are  exerting  about  the  full  force  of  the  spring  of  the  rods  with- 
out permanently  bending  them.  In  this  condition  the  specimen 
is  again  placed  in  the  warming  box. 

Any  number  of  specimens  of  teeth  or  bits  of  teeth,  bone,  etc., 
which  the  face  of  the  disk  will  hold  may  be  placed  on  the  disk, 
and  all  may  be  ground  together.  Four  to  six  lengthwise  sections 
of  incisor  or  cuspid  teeth  may  be  placed  at  once,  or  eight  to 
twelve  cross  sections.  It  seems  to  be  best,  however,  not  to  load 
the  disk  too  heavily,  and  to  place  nothing  on  the  central  part  of 
the  disk.  In  other  words,  specimens  should  be  placed  as  near 
the  periphery  of  the  disk  as  possible,  so  that  each  will  sweep  over 
the  entire  breadth  of  the  stone.  Four  lengthwise  sections  will 
be  ground  better  than  six,  as  a  rule. 

After  the  loaded  disk  has  remained  in  the  warming  box  until 
all  balsam  that  will  come  has  been  squeezed  out  from  under  the 
specimens,  the  excess  of  balsam  should  be  very  carefully  removed 
close  up  against  the  specimens.  The  best  instrument  for  remov- 
ing this  is  a  wooden  toothpick  with  a  flat  end  cut  squarely  across. 
When  this  is  pushed  against  the  balsam  it  will  rise  up  on  the 
toothpick,  and  it  may  be  wiped  away  with  a  cloth  held  in  the 
other  hand.  Nothing  clogs  a  stone  and  stops  its  cutting  more 
effectually  than  balsam  smeared  over  it,  and  all  excess  which 
may  come  in  contact  with  the  stone  should  be  removed. 

The  spider  should  then  be  returned  to  the  warming  box  for 
from  one  to  four  hours,  so  that  it  may  dry  a  little  about  the 
margins.  Then  it  may  be  removed  and  allowed  to  cool,  and 
await  convenience  in  grinding.  It  should,  however,  remain 
secured  on  the  spider  by  the  dogs  if  it  is  to  wait  more  than  a  few 
hours,  for  the  disposition  of  dentin  to  warp  in  drying  may  pull 
some  part  of  the  specimen  from  the  disk.  Under  these  condi- 
tions, two  or  three  days,  or  a  week,  will  do  no  harm. 

When  the  grinding  is  completed,  the  disk  is  removed  from 
the  machine  and  the  specimens  flushed  with  clean  water,  and 
dried  by  the  pressure  of  a  soft  napkin  folded  to  several  thick- 
nesses, or  clean  pieces  of  waste-cotton  fabric  may  be  used.  Then 
the  disk,  with  its  specimens,  should  be  laid  in  a  dish,  and  suffi- 
cient xylol  added  to  cover  it,  and  allowed  to  rest  until  the 
balsam  has  been  dissolved  and  the  specimens  released.  This 
will  usually  require  from  twenty  to  thirty  minutes,  or  sometimes 
as  much  as  an  hour.  When  the  specimens  are  very  thin  they 
loosen  much  quicker  than  when  thick.  Any  material  not  pene- 
trated by  xylol,  as  silicified  petrifactions  and  stones,  require 
much  more  time. 


GRINDING   MICBOSCOPIC    SPECIMENS.  469 

When  the  specimens  have  loosened,  they  are  ready  for  per- 
manent mounting  for  microscopic  study. 

Rapidity  of  grinding. 

In  order  to  make  rapid  progress  in  grinding  specimens,  one 
should  have  six  to  ten  grinding  disks,  nearly  as  many  spiders, 
and  a  large  supply  of  dogs.  The  machine  is  so  nearly  automatic 
in  its  action  that  it  needs  but  little  watching,  so  that  the  prepara- 
tion may  be  going  on  while  the  grinding  is  in  progress.  One  of 
the  principal  points  which  needs  attention  is  the  flow  of  water. 
But  if  the  water  and  ice  placed  in  the  receptacle  are  clean  and 
free  from  dirt  which  may  stop  the  flow  of  water,  the  only  care 
is  that  the  quantity  of  water  is  kept  up.  The  vessel  should  be 
large  enough  to  hold  a  supply  for  several  hours.  If  the  stone 
should  run  dry,  the  specimen  would  be  destroyed  in  a  few 
seconds. 

Setting  the  measurement  of  grinding  "disks. 

When  beginning  a  series  of  grindings,  the  first  thing  of 
importance  is  to  try  out  and  obtain  a  record  of  the  measure- 
ments of  each  grinding  disk  for  the  particular  stone  that  may  be 
selected  for  finishing.  I  find  that  most  persons,  after  some 
practice,  prefer  to  use  a  fine  stone  for  the  entire  grind.  In 
grinding  teeth,  after  roughing  down  the  surface  which  is  to  form 
the  specimen,  the  back  is  also  ground  away  to  a  flat  surface, 
which  will  better  accommodate  the  placing  of  dogs  in  mounting 
on  the  grinding  disks.  These  may  be  made  quite  thin  and  reduce 
the  grinding  with  the  fine  stone.  The  stone  selected  is  placed  in 
the  lathe  head,  seeing  to  it  carefully  that  the  face  of  the  stone  is 
clean.  The  grinding  machine  is  brought  up  in  contact  with  the 
set-screw  of  the  point  finder.  Then,  with  the  large  nut  the  shaft 
is  so  adjusted  that  the  grinding  disk  being  tried  comes  close  to 
the  stone  but  does  not  touch  it.  The  machine  should  be  started 
and  its  running  carefully  noted.  Wliile  doing  so  the  adjusting 
nut  of  the  micrometer  should  be  moved  one-thousandth  of  an 
inch  at  a  time  backward  to  lengthen  the  shaft,  listening  for  the 
first  touch  of  the  disk  to  the  stone.  The  moment  this  is  heard, 
if  the  machine  does  not  stop,  it  is  because  the  adjustment  is  such 
that  the  stopping  device  is  not  thrown.  In  that  case  the  nut  of 
the  micrometer  is  screwed  forward  and  tried  again  until  the 
machine  is  stopped  exactly  when  the  first  scrape  upon  the  stone 
is  heard.  The  click  of  the  switch  which  stops  the  current  will 
also  be  heard  at  the  same  time.     If,  on  the  other  hand,  the  click 


470  SPECIAL    DENTAL   PATHOLOGY. 

of  the  switch  is  heard  before  the  disk  reaches  the  stone,  the 
micrometer  nut  must  be  screwed  backward  to  increase  the  length 
of  the  shaft  just  enough  so  that  the  click  of  the  switch  is  heard 
at  the  same  time  the  disk  touches  the  stone.  A  little  practice 
will  make  the  adjustment  easy. 

After  this  is  completed  for  any  given  stone,  or  for  all  of  the 
stones,  this  record  is  used  for  the  setting  of  disks  for  grinding. 
This  record  is  made  upon  a  white  card  and  hung  where  it  will  be 
before  the  operator.  At  each  placement  of  a  disk  it  may  be  tried 
out  before  the  setting  of  the  specimens  upon  it,  placing  the 
adjusting  nut  at  the  recorded  measurement  to  see  that  it  is 
exactly  correct.  Then  the  adjusting  nut  is  turned  forward  as 
many  thousandths  as  the  desired  thickness  of  the  specimen  and 
made  fast  by  tightening  the  brake.  Then  the  grinding  may  pro- 
ceed, first  seeing  that  the  ice-water  is  running,  and  will  not 
require  any  special  notice  until  the  machine  stops.  Then  the 
disk  is  dried  off  and  placed  in  the  bath  of  xylol  to  dissolve  off  the 
specimen.     Another  disk  is  adjusted  and  the  grinding  proceeds. 

Recently  an  assistant  in  my  laboratory  was  grinding  sec- 
tions of  teeth,  and  he  made  all  of  the  preparations,  preparatory 
grindings,  disk  mounts,  and  ground  and  removed  from  the  disks 
ready  for  mounting,  forty  full-length  sections  of  central  incisors 
in  six  hours,  and  had  his  luncheon  in  the  meantime.  Every 
section  was  complete,  of  even  thickness  in  every  part,  and  all 
practically  the  same  thickness.  During  the  past  winter  six  hun- 
dred specimens  were  ground  without  changing  the  micrometer. 
It  was  then  discovered  that  the  specimens  being  ground  were  too 
thick,  and  a  change  of  1/1000  of  an  inch  was  found  necessary  to 
make  them  thin  enough.  This  difference  represented  the  wear 
of  the  stone  in  that  series  of  grindings.  It  will  be  seen  that  this 
is  not  very  much,  but  it  is  an  item  which  requires  special  notice. 

Grinding  frail  material. 

While  the  machine  facilitates  the  production  of  the  more 
ordinary  sections  to  such  a  degree  as  to  be  indispensable  to  one 
having  many  grindings  to  do,  it  is  in  the  production  of  sections 
of  very  frail  material  that  the  grinding  machine  stands  out  as 
vastly  superior  to  the  other  methods  of  grinding.  In  the  study 
of  caries  of  enamel  in  which  disintegration  has  rendered  the 
remaining  tissue  very  frail  and  likely  to  fall  to  pieces  before  it 
is  sufficiently  thin,  we  may  obtain  the  required  thinness  and  yet 
retain  all  of  the  tissue.  I  have  also  produced  exceedingly  fine 
sections  of  salivary  calculus,  and  equally  good  sections  from 


GRINDING    MICEOSCOPIC    SPECIMENS.  471 

small  crumbs  of  sermnal  calculus.  The  production  of  these  is 
slow,  but  fairly  certain  of  good  results. 

Also  in  grinding  sections  of  fossil  teeth,  fossil  woods,  and 
the  like,  in  which  very  fine  sections  are  too  brittle  to  be  handled 
in  any  way  except  as  stuck  to  glass,  the  machine  gives  excellent 
results.  In  geological  work  it  practically  removes  the  difificul- 
ties.  Good  sections  of  the  very  brittle  stones  can  be  made  with 
fair  safety  by  grinding  on  the  cover-glass. 

Much  very  desirable  material  for  microscopic  investigation 
is  so  frail,  or  at  least  so  brittle,  when  reduced  to  sections  thin 
enough  for  microscopic  investigation,  that  it  will  crumble  to 
pieces,  either  in  the  grinding  or  in  the  mounting,  by  the  ordinary 
procedures.  For  grinding  and  mounting  such  material  the 
following  processes  have  been  slowly  evolved.  These  may  be 
divided  into  the  balsam  process  and  the  shellac  process.  Mate- 
rial may  be  made  fast  to  a  cover-glass  and  ground  in  hard 
balsam,  if  it  is  not  liable  to  go  to  pieces  when  this  hard  balsam 
is  softened  by  sticking  the  specimen  and  glass  cover  to  a  glass 
slide.  If,  however,  the  different  parts  are  liable  to  separate  and 
change  position  when  the  balsam  softens,  shellac  should  be  used 
for  the  grinding.  I  have  been  much  disappointed  by  failures  in 
grinding  in  hard  balsam  rare  specimens  of  enamel  which  had  no 
cementing  substance  between  the  enamel  rods.  When  the  softer 
balsam  was  added  to  mount  the  specimens  on  the  glass  slides, 
the  hard  balsam  was  softened  and  the  enamel  rods  floated  out  of 
position.  All  such  material  as  will  not  hold  together  should  be 
ground  in  shellac. 

The  use  or  balsam.  To  grind  in  hard  balsam,  the  one  side 
of  the  specimen  may  be  ground  flat  on  the  rough  stone  and  then 
dried  out  in  absolute  alcohol.  The  ground  side  should  be  satu- 
rated to  sufficient  depth  with  soft  balsam,  and  laid  aside  until 
the  balsam  has  become  hard  enough  to  grind  smoothly.  Then 
the  grinding  and  polishing  of  this  first  side  should  be  completed 
by  grinding  away  all  balsam  from  the  immediate  surface,  and 
sufficiently  into  the  substance  of  the  specimen  to  produce  a  clean, 
smooth  surface  of  the  material.  When  this  has  been  done,  and  the 
surface  dried,  it  should  be  mounted  on  an  ordinary  cover-glass, 
the  thickness  of  which  should  have  been  measured  and  recorded. 
In  this  mounting  the  cover-glass  should  be  laid  on  a  spider  and 
weight  enough  placed  upon  it  to  insure  a  perfect  fit  of  the  sur- 
face of  the  glass.  This  should  be  subjected  to  about  120°  F. 
for  from  one  to  five  or  six  hours,  for  the  purpose  of  expressing 
the  last  bit  of  balsam  possible  from  between  the  specimen  and 


472  SPECIAL   DENTAL   PATHOLOGY. 

the  cover-glass.  Then  it  may  rest,  awaiting  the  convenience  of 
the  operator,  for  several  days,  but  the  balsam  must  not  be 
allowed  to  become  "brittle  hard,"  because  in  that  case  it  loses 
touglmess.  All  excess  of  balsam  about  the  margins  of  the  speci- 
men should  be  carefully  removed  to  facilitate  the  hardening  of 
that  which  remains,  and  especially  so  that  it  may  not  come  in 
contact  with  the  grinding-stone,  stick  to  its  surface,  and  interfere 
with  the  cutting. 

Good  judgment  must  be  acquired  by  practice  as  to  the 
hardening  of  balsam  and  shellac  in  these  grinding  processes. 
The  best  idea  of  it  that  can  be  given  in  words  is  this:  The 
balsam  or  the  shellac  must  have  become  firm  enough  so  that  it 
will  not  drag  or  allow  the  specimen  to  move  while  grinding  in 
iced  water.  Neither  must  it  become  hard  enough  to  become 
brittle,  for  then  it  is  liable  to  break. 

When  ready,  the  specimen  is  mounted  on  the  grinding  disk. 
This  is  done  by  first  cleansing  the  disk,  finishing  with  xylol,  and 
then  sealing  the  cover-glass  to  this  with  soft  balsam.  This 
should  be  placed  on  the  spider  and  well  weighted  down  with 
dogs.  All  excess  of  balsam  should  be  carefully  removed  from 
the  margins  of  the  cover-glass.  This  may  be  quickly  dried  at 
120°  F.,  or  more  slowly  at  room  temperature.  It  should,  how- 
ever, be  warmed  for  a  half  hour  or  more,  for  the  purpose  of 
expressing  as  much  balsam  as  possible.  This  cover-glass  will 
be  well  held  for  grinding  in  iced  water  with  only  a  little  drying 
about  the  margins,  if  all  excess  of  balsam  is  cleaned  away  closely. 
The  balsam  should  not  become  very  hard. 

If  the  specimen  is  of  considerable  bulk  and  of  a  quality  of 
material  that  can  be  cut  with  a  steel  saw,  the  disk  may  be  caught 
in  a  vise  with  leather-cushioned  jaws  to  avoid  bruising,  and  the 
bulk  of  the  material  removed  with  a  jeweler's  saw,  leaving  only 
a  moderately  thin  section  for  grinding.  Or  if  the  material  ift 
very  hard,  as  stones,  silicified  fossils,  etc.,  the  disks  may  be 
mounted  upon  the  slide  rest  and  cut  with  the  slicing  disks, 
previously  described. 

Tlie  specimen  is  now  ready  for  the  final  grinding.  The 
record  for  measurement  with  the  particular  stone  to  be  used  in 
finishing  has  been  made,  tried  out  on  unimportant  material,  and 
the  cover-glass  has  been  measured  and  its  record  made.  With 
this  data,  the  disk  is  screwed  to  its  place,  the  micrometer  turned 
to  the  proper  measurement  for  the  finish,  the  iced  water 
arranged,  the  machine  set  in  motion,  and  it  will  do  the  rest. 
^Vhen  coarser  stones  are  used  for  cutting  away  much  material, 


GRINDING    MICROSCOPIC    SPECIMENS.  473 

I  find  those  with  just  a  little  experience  prefer  to  gauge  the 
amount  of  the  cutting  by  the  eye  for  the  coarse  stone. 

Removal  of  the  cover-glass  from  the  disk.  I  remove  the 
<'Over-glass  with  the  specimen  from  the  grinding  disk  in  two 
different  ways,  as  seems  at  the  time  best. 

First,  the  grinding  disk  is  placed  on  a  heated  piece  of  metal 
that  will  warm  the  grinding  disk  quickly.  A  stick  of  rather  soft 
wood,  the  end  of  which  is  cut  to  a  sharp  angle  and  thinned  down 
almost  in  the  form  of  a  blade,  is  held  ready.  When  the  grinding 
disk  begins  to  warm,  the  margin  of  the  cover-glass  is  caught  with 
the  end  of  the  stick  and  steady  pressure  is  made.  As  the  disk 
warms,  softening  the  balsam,  the  cover-glass  will  begin  to  move 
under  the  steady  pressure,  slowly  at  first,  but  more  rai3idly  later, 
and  will  slide  off  the  grinding  disk  before  the  specimen  is 
loosened.  For  this  plan  the  cover-glass  should  be  pretty  strong, 
one  and  one-half  to  two  thousandths  of  an  inch  thick ;  otherwise 
there  will  be  great  danger  of  breaking  it.  It  is  well  in  some  cases 
to  run  just  a  little  xylol  around  the  margins  of  the  cover-glass 
and  partially  dissolve  the  balsam  which  has  become  dryest,  before 
the  heating.  Great  care  must  be  taken  not  to  allow  the  xylol  to 
spread  on  to  the  specimen,  for  it  would  loosen  it  very  quickly. 

The  specimen  is  then  turned  downward  and  placed  on  a  tiny 
drop  of  balsam  on  a  glass  slide,  and  quickly  pressed  down  close 
and  level.  As  the  new  balsam  will  soften  the  old,  a  spring  clip 
should  be  quickly  applied  to  hold  it  steady.  The  parts  of  the 
specimen  are  less  likely  to  move  if  this  is  laid  on  ice  for  an  hour 
or  more. 

The  use  of  shellac  In  the  second  plan  shellac  is  used 
instead  of  balsam  for  hardening  the  specimen  and  holding  its 
I)arts  together  in  the  first  grinding.  This  part  of  the  work  is 
otherwise  done  in  the  same  way.  The  drying  of  the  shellac 
usually  requires  more  time  than  the  balsam. 

The  attachment  of  the  cover-glass  to  the  grinding  disk  is 
done  in  the  same  way  as  when  l)alsam  is  used  to  hold  the  spci- 
men  on  the  cover-glass.  The  grinding  proceeds  similarly  in 
every  respect. 

The  important  difference  in  the  two  processes  is  in  tlie 
T'eraoval  of  the  cover-glass  from  the  grinding  disk,  and  niountiiig 
the  specimen.  Xylol  dissolves  balsam  very  quickly;  but  xylol 
does  not  dissolve  shellac  at  all.  Therefore,  instead  of  pushing 
the  cover-glass  off  the  grinding  disk,  the  disk  is  laid  in  xylol 
and  the  balsam  dissolved  out.  In  this  there  is  no  danger  of 
detaching  or  moving  the  specimen  if  it  is  carefully  haiKllcd. 

43 


474  SPECIAL   DENTAL    PATHOLOGY. 

When  cleaned,  it  is  inverted  upon  a  glass  slide  on  a  drop  of 
balsam  without  fear  of  movement  of  parts  of  the  specimen,  no 
matter  how  frail. 

The  preparation  of  shellac.  It  is  difficult  to  keep  shellac 
in  condition  for  this  work.  The  dry  scales  should  be  dissolved 
in  absolute  alcohol  so  as  to  make  a  moderately  thick  varnish. 
It  should  then  be  filtered  at  a  temperature  of  110°  F.  to  120°  F., 
or  made  thinner  and  filtered  at  room  temperature.  Great  care 
should  be  exercised  to  keep  the  filtrate  from  exposure  to  a  damp 
atmosphere,  for  it  absorbs  water  readily  and  then  will  throw 
down  fine  crystals,  which  destroy  its  value  for  microscopic 
purposes. 

After  being  filtered  it  should  be  evaporated  in  a  close  wann- 
ing box  at  about  110°  F.  to  120°  F.,  to  the  consistence  of  syrup. 
In  doing  this  it  is  well  to  divide  the  supply  into  two  or  three 
grades  —  a  thinner,  a  medium,  and  a  thicker  solution.  The  thin- 
ner solution  will  be  used  for  saturating  frail  specimens  before 
cutting;  the  thicker  solutions  for  attaching  specimens  to  the 
cover-glass  for  grinding,  and  the  medium  solution  for  either 
purpose,  as  the  material  may  seem  to  require. 

Grinding  from  crumbled  material. 

Often  important  material  for  investigation  can  be  had  only 
in  very  small  crumbs,  or  broken  pieces,  such  as  serumal  calculus, 
sands,  crumbled  bits  of  strange  stones,  or  mixtures  of  such  mate- 
rial as  is  found  in  some  of  the  coarser  sands.  These,  on  micro- 
scopic investigation,  may  reveal  their  origin  and  throw  light 
upon  geological  questions.  In  addition  to  the  ordinary  micro- 
scopic observation,  the  polariscope  may  be  turned  on  these,  and 
reveal  facts  as  to  their  origin  and  structure.  Also  many  things 
will  be  found  in  botanical  work,  such  as  sections  of  small  seeds, 
and  the  like,  which  will  give  useful  information. 

Having  done  a  few  of  these  grindings,  especiallj^  of  the  very 
frail  dental  material,  such  as  serumal  calculus,  extremely  frail 
fossil  teeth,  etc.,  plans  of  work  more  or  less  well  adapted  have 
been  developed.  For  instance,  I  have  obtained  excellent  sections 
of  serumal  calculus,  which  can  be  had  only  in  small  crumbs  or 
flakes.  A  small  collection  of  these  bits  are  first  immersed  for  a 
time  in  absolute  alcohol,  or  until  all  air  has  been  removed,  if  they 
are  dry,  or  if  they  are  freshly  gathered,  until  all  water  has  been 
removed.  Then  a  cover-glass  is  prepared  by  covering  its  central 
part  with  the  thicker  solution  of  shellac,  and  these  crumbs  are 
I)laced  in  this,  in  what  seems  to  be  the  best  position  for  obtain- 


GRINDING    MICROSCOPIC    SPECIMENS.  475 

ing  sections.  These  are  allowed  to  soak  full  of  the  shellac,  under 
a  close  cover,  and  then  uncovered  to  dry  up.  If  some  of  the 
pieces  seem  to  need  it,  more  shellac  is  added  from  time  to  time, 
until  the  embedding  is  sufficient.  This  may  be  dried  at  room 
temperature,  or  in  the  warming  oven  at  110°  F.  to  120°  F. 
Shellac  should  not  be  subjected  to  much  higher  temperatures  for 
a  considerable  time,  because  continued  high  temperature  for 
many  days  together  seems  to  injure  its  strength. 

When  this  is  sufficiently  hard  for  smooth  grinding,  and 
before  it  has  become  too  brittle  (determining  this  point  requires 
some  experience),  the  preparation  is  cemented  to  the  grinding 
disk  with  balsam  and  ground  to  such  a  point  as  seems  most 
favorable  for  obtaining  sections.  This  point  is  to  be  determined 
by  frequent  removal  of  the  disk  from  the  machine  and  examina- 
tion of  the  exposed  surfaces  of  the  several  pieces. 

When  this  part  is  done,  the  cover-glass  is  dissolved  off 
the  grinding  disk  by  xylol.  Then  another  cover-glass  is  attached 
to  the  surface  with  the  least  possible  amount  of  shellac.  This 
in  turn  is  dried  to  the  right  consistence.  Then  the  last  cover- 
glass  placed — that  is,  the  one  on  the  side  that  has  been  ground — 
is  secured  to  the  grinding  disk  with  balsam.  When  this  has  set 
it  is  placed  on  the  machine  and  the  first  cover-glass  is  ground 
away  and  the  section  ground  to  the  required  thinness.  They 
are  again  dissolved  oft'  the  grinding  disk,  and  may  he  at  once 
mounted  in  balsam  on  the  microscopic  slide. 

By  somewhat  similar  methods  I  have  obtained  excellent 
specimens  of  the  fossil  teeth  of  the  mastodon,  the  dentin  of 
which  was  so  frail  as  to  crumble  in  the  fingers.  Yet  the  finished 
specimen  showed  all  of  the  tissues  as  perfectly  as  if  it  had  been 
from  a  fresh  tooth. 

Difficulties  in  grinding. 

In  the  grinding  of  material  enveloped  in  shellac,  or  in 
balsam,  either  of  these  materials  is  apt  to  gum  up  the  stone 
and  stop  the  cutting,  or  render  the  grinding  very  slow.  For 
the  finishing  of  any  piece  being  ground  when  this  is  noticed,  the 
stone  may  be  much  improved  by  drying  it  and  washing  with 
xylol  on  a  brush,  or  a  bit  of  cloth,  while  the  stone  is  slowly 
revolved.  When  gummed  with  shellac,  the  washing  is  done  with 
absolute  alcohol.  In  case  the  stone  l)ecomes  clogged  with  balsam 
the  best  treatment  is  to  place  it  in  a  dish  with  sufficient  xylol  to 
cover  it  and  let  stand  over  night,  closely  covered.  The  stone  will 
then  be  in  as  good  condition  as  it  was  at  first.     If  the  stone  has 

*43 


476  •  SPECIAL    DENTAL    PATHOLOGY. 

become  smeared  with  shellac  it  should  be  placed  in  a  dish,  with 
sufficient  absolute  alcohol  to  cover  the  stone,  and  allowed  to 
remain  over  night. 

With  much  grinding  of  hard  substances,  the  surfaces  of  the 
stones  become  worn  so  smooth  that  they  do  not  cut  well.  Then 
the  picking  tool  should  be  run  over  the  surface  until  it  is  per- 
ceptibly roughened.  This  will  cause  the  stone  to  cut  briskly  for 
a  time,  and  at  first  —  following  such  sharpening  —  the  ground 
surface  of  the  specimen  is  likely  to  be  full  of  scratches.  In  that 
case  a  smooth  stone  should  be  used  for  the  finishing. 

Much  care  should  be  taken  in  keeping  the  stones  in  good 
condition.  Except  in  the  ways  mentioned,  no  dirt  or  grit  should 
be  allowed  to  come  in  contact  with  their  surfaces.  A  single 
particle  of  grit  lodged  in  the  surface  of  the  stone  will  fill  the 
whole  surface  of  the  ground  section  with  scratches.  Although 
I  keep  these  stones  in  a  closely  fitting  drawer,  it  is  necessary  to 
cover  each  with  a  cloth  that  is  so  closely  woven  as  to  exclude  all 
dust. 

In  taking  care  of  the  machine  itself,  one  can  not  be  too  care- 
ful. All  of  the  bearings  of  the  lathe  head  and  of  the  grinding 
machine  should  be  swaddled  with  candle-wick  saturated  with  oil 
to  prevent  the  ingress  of  gritty  particles.  This  is  especially 
needful  when  using  the  aluminum  saws  and  feeding  them  with 
carborundum  powder.  Then  every  bearing  about  the  whole 
machine  should  be  especially  protected  to  prevent  the  possibility 
of  getting  grit  in  the  bearings.  Carelessness  in  such  a  matter 
will  quickly  ruin  a  fine  bit  of  mechanism.  But  with  this  care, 
such  a  machine  should  continue  to  do  its  work  well  for  a  lifetime. 


INDEX 


Abnormal  forms  of  teeth  as  a   cause  of 

gingivitis,  131. 
Abnormalities  of  occlusion  as  a  cause  of 

gingivitis,  130. 
Abrasion,   calcification   of  pulp   resulting 

from,  see  calcifications  of  pulp, 
treatment  of,  277. 
Abscess,  acute  alveolar,  336. 
absorption  of  bone.  337. 
apical  pericementitis,  337. 
burrowing  of  pus  in  severe  cases,  357. 
cementum,  if  denuded,  maintains  chro- 

nicity,  341. 
chronicity   maintained  by   denuded  ce- 
mentum, 341. 
constitutional  symptoms,  343. 
differential  diagnosis,  345. 

aneurism,  346. 

cysts,  346. 

eruption  of  third  molars,  347. 

examine  fluid  contents,  347. 

glands,  347. 

gumma,  346. 

sarcoma,  346. 
distinctions    between    alveolar    abscess 

and  abscesses  elsewhere,  341. 
etiology,  336. 

if  pus  lifts  periosteum  from  bone,  340. 
if  pus  penetrates  periosteum,  340. 
infection  from  pulp  chamber,  341. 
local  symptoms,  34.3. 
pain,  344. 
pain  disappears  with  discharge  of  pus, 

345. 
pathological  changes,  337. 
pericementitis,  337. 
prophylaxis,  360. 
pus  formation,  337. 

pus,  variations  in  burrowing,  340,  357. 
swelling.  344. 
symptoms,  343. 
tenderness  of  tooth,  343. 
tumor,  ball-like,  344. 
tumor,  flat,  345. 
treatment,  350. 

advantages  of  early  incision,  352. 

anesthesia  for  incision,  353. 

anodynes,  356. 

apical  pericementitis,  treatment  dur- 
ing, 350. 

drainage  in  severe  cases,  357. 

drainage,  secure  good,  351,  352. 

flrainage    through    investing    tissues, 
351. 

drainage  through  pulp  chamber,  351. 

hot  fomentatioTis,  356. 


incision,  anesthe^sia  for,  3.53. 
incision  early,  advantages  of,  352. 
incision  in  cases  of  broad  flat  tumors 

under  periosteum,  353. 
incision,  if  pus  has  not  reached  peri- 
osteum, 353. 
incision    should    be   ample   for   good 

drainage,  352. 
irrigation,  354. 

open  pulp  chamber  after  acute  symp- 
toms have  subsided,  355. 
opening  made  with  phenol,  353. 
packing,  354. 

pain,  relief  of,  in  severe  cases,  356. 
pericementitis,  treatment  during,  350. 
phenol  to  make  opening,  353. 
treatment  of  more  severe  cases,  355. 
saline  cathartic,  356. 
secure  good  drainage,  351. 
symptoms,  relief  of,  in  severe  cases, 
356. 
Abscess,  chronic  alveolar,  362. 
absorption  of  bone,  369. 
blind,  365. 
cementum,    extent    to    which    denuded, 

371. 
chronicity   maintained   by   denuded  ce- 
mentum, 363. 
classification,  365. 
deposits  of  serumal  calculus,  368. 
detachments  from  cementum  permanent 

and  maintain  chronicity,  363. 
diagnosis,  368. 

discharging  through  root  canal,  365. 
etiology,  362. 
from  deciduous  teeth,  333. 
if  dead  pulp  remains  in  tooth,  363. 
if  periapical  tissue  destroyed  by  acute 

abscess,  363. 
if  periapical  tissue  destroyed  by  drugs, 

363. 
loosening  of  tooth,  369. 
pain,  368. 

])athoI()gical  changes,  363. 
jieriapical  tissues,  destruction  of,  363. 
juilp  of  tooth  dead,  369. 
]>ulp  of  tooth  removed,  369. 
pus,  discharge  of,  369. 
radiographs,  371. 

serumal  calculus,  deposits  of,  368. 
sharj).    stiff    steel    probe    for    examina- 
tion, .'{71. 
sinus  openings,  variations   in    ]n)sitions 

of,  365. 
subperiosteal   bone,   deposition   of,  367. 
tenderness  of  tooth,  368. 


478 


SPECIAL    DENTAL.   PATHOLOGY, 


Abscess,  chronic  alveolar  (continued), 
treatment,  373,  37/). 

amputation  of  roots  of  molar  teeth, 

379. 
blind  abscess,  376. 
historical  statement,  373. 
resection    of    roots,    possibilities    of 

healingf,  378. 
resection  of  roots,  technie,  378. 
treatment  of  blind  abscess.  376. 
treatment  of  root  canal,  375. 
treatment,    practice   in   vogue   should 

be  discontinued,  377. 
when  sinus  does  not  heal,  376. 
with  intermittent  discharge,  365. 
with  sinus,  365. 
Abscess,    differential    diagnosis    between 
gingival,  septal   and   lateral  alveolar 
abscess,    and    true    alveolar    abscess, 
181. 
Abscess,  gingival.  179. 
Abscess,  lateral  alveolar,  179. 
Abscess,  septal,  179. 

Absorption  of  bone,  in  acute  alveolar  ab- 
scess, 337. 
in  chronic  aheolar  abscess,  368. 
in    chronic    suppurative    pericementitis, 
168. 
Absorption  of  cementum,  32. 
Absorption  of  cementum  and  dentin,  re- 
pairs of,  33,  42. 
Absorption   of   roots,  of  deciduous   teeth. 
330. 
of  permanent  teeth,  33. 
Absorption,  pathological,  of  roots  of  per- 
manent teeth,  33. 
Abuse  of  tissues  by  dentists  as  a  cause  of 

gingivitis,  135. 
Acute  alveolar  abscess,  see  abscess. 
Acute  ulcerous  gingivitis,  230. 
Accidental  injuries  to  the  gingiva",  139. 
Admixtures  of  cases  of  chronic  suppura- 
tive pericementitis  and  inflammations 
caused   by   deposits   of   salivary   cal- 
culus, 182. 
Agglutinin  of  salivary  calculus,  89. 
Albumin  in  saliva,  60. 
Alveolar  abscess,  see  abscess. 
Alveolar  abscess,  danger  of,  in  calcifica- 
tion of  pulp  tissue,  274. 
Alveolar  crest  group  of  fibers  of  periden- 
tal membrane,  16. 
Alveolar  process. 

absorption    of,    best    shown    by    radio- 
graphs, 169. 
in  acute  alveolar  abscess,  337. 
in  chronic  alveolar  abscess,  369. 
destruction  of,  in  cases  of  chronic  sup- 
purative pericementitis,  168. 
development  of,  52. 

difi^erences   between    bone    and    cemen- 
tum, 32. 
diseases,  62. 
functions  of,  7,  30,  50. 


histology  of,  7,  30,  50. 
historical   review  of  knowledge  of  dis- 
eases. 64. 
movements  of  teeth  subsequent   to  ex- 
tractions. 54. 
names  applied  to  diseases  of.  64. 
I)hysical  functions  of  7,  30,  50. 
y)rocesses  are  bone,  51. 
results    of    break    in    peridental    mem- 
brane, 53. 
treatment,  62. 

when  teeth  are  extracted,  53. 
when  teeth  are  malposed,  53. 
Alveolitis,  65. 

Amputation  of  roots,  in  chronic  alveolar 
abscess,  379. 
in    chronic    suppurative    pericementitis, 
205. 
Analysis  of  salivary  calculus,  74. 
Anesthesia  for  incision  in  acute  alveolar 

abscess,  353. 
Aneurism,  differential  diagnosis  from  al- 
veolar abscess,  346. 
Animals,  cementum  of,  35. 
Anodynes,  in  acute  alveolar  abscess,  356. 

in  necrosis,  384. 
Antiseptic  period  in  surgery,  218. 
chronological  list  of  events,  225. 
surgery,  development  of,  217. 
Antiseptics,    abandonment    of,    in    treat- 
ment of  chronic  suppurative   perice- 
mentitis, 210. 
author's  studies  of,  222. 
experiments    with    those    used    in    pulp 

treatment,  296. 
use   of,   generally   lessened   in   surgery, 

220. 
use  of,  in  surgery,  217. 
Apical  group  of  fibers  of  peridental  mem- 
brane, 39. 
Arsenic  in  pulp  treatment,  see  pulp. 
Artificial  dentures,  cleaning  of,  442. 
deposits  of  salivary  calculus  on,  80. 
forms  of,  to  avoid  deposits  of  salivary 
calculus,  104. 
Asepsis,  in  pulp  treatment,  287. 

in    treatment    of    teeth    having    dead 
pulps,  322. 
Aseptic  period  in  surgery,  220. 

chronological  list  of  events,  225. 
Aseptic  surgery,  development  of,  217. 
Author's  investigations  of  salivary  calcu- 
lus, 79. 
investigations    of    calcifications    in    the 

pulp  chamber,  266. 
studies  of  antiseptics.  222. 
studies  of  hyperemia  and  inflammation 
of  the  dental  pulp,  251. 

Billings'  investigations  of  systemic  effect 

of  chronic  infections  of  mouth,  401. 
Blind  abscess,  see  abscess. 
Blood  supply  of  ginns  and  gingivte,  9. 
Blood  vessels  of  peridental  membrane,  40. 


INDEX. 


479 


Blood  vessels  of  pulp,  236. 

walls  of,  237. 
Body  of  the  gingivag,  13. 
Bone,  absorption  of,  in  acute  alveolar  ab- 
scess, 337. 
in  chronic  alveolar  abscess,  368. 
Bone,   differences   as   compared   with    ce- 

mentuni,  32. 
Bone  of  alveolar  process,  51. 
absorption  of 

in  acute  alveolar  abscess,  357. 
in  chronic  alveolar  abscess,  369. 
in  chronic  suppurative  pericementitis, 
168. 
development  of,  52. 
Bridges,  cleaning  of,  442. 

as  a  cause  of  gingivitis.  134. 
Broaches,  technic  of  sterilizing,  289. 

technie  of  wrapping  cotton  on,  289. 
Brushing  by  patients  to  prevent  deposits 

of  salivary  calculus.  111. 
Brushing  the  teeth,  see  mouth  hygiene. 
Burchard's  studies,  salivary  calculus,  76. 

Calcic  gingivitis,  65. 

Calcic  pericementitis,  65. 

Calcification  of  roots  of  deciduous  teeth, 

330. 
Calcifications    in    the    pulp    chamber   and 
their  eifects  on  the  pulp  tissue,  265. 
attached  to  walls  of  pulp  chamber,  267, 
abraded  dentin  becomes  darker,  271. 
alveolar  abscess,  danger  of,  274. 
calcification  more  extensive  as  abra- 
sion progresses,  268. 
effect  on  dentin  and  enamel,  271. 
effect  on  pulp  tissue,  272. 
etiology,  267. 
exposure    of    pulp    by    abrasion   aud 

erosion,  272. 
fibrils  of  dentin  die,  271. 
nature  and  conditions  of  growth,  268. 
protection  for  pulp,  268. 
secondary    dentin    deposited    through 
reflex  action,  not  a  local  forma- 
tion, 269. 
author's  investigations,  266. 
classification,  265. 
generally  no  symptoms,  276. 
growing  free  in  tissue  of  pulp,  274. 
nontuhular  calcifications,  267. 
pulp  nodules.  274. 
tendency  to  destroy  pulp,  276. 
treatment,  27(5,  324. 

building  up  extensive  abrasions.  278. 
danger   of  approaching  too   close  to 
pulp  in  cavity  preparation,  279. 
of  abrasion.  277. 
of  erosion,  279. 
variety  of  forms,  274. 
Caleo-globulin,    in    cases    of    deposits    of 

serumal  calculus,  115. 
Calco-globulin.  in  connection  witli   ilejios- 
its  of  salivary  calculus,  102. 


Calco-globulin,  see  salivary  calculus. 
Calco-spherites,  formation  of,  280. 

artificial  formation  of,  281. 
^  importance  of  studies  of,  283. 
Calculus,  deposits  of,  see  gingivitis  caused 
by  deposits  of  salivary  calculus  and 
of  serumal  calculus, 
in  cases  of  injury  to  gingivae,  128. 
Capping  exposures  of  the  dental  pulp.  301. 
indications  for  capping,  303. 
technic  of  capping,  303. 
time  of  complete  calcification  of  roots. 
303. 
Carbon  dioxid  in  saliva  in  relation  to  de- 
posits of  salivary  calculus,  76. 
Card   for  record  of  mouth  examinations, 

457. 
Caries  beginning  in  proximal  surfaces  as 

a  cause  of  gingivitis,  131. 
Caries,    dental,   application    of   oral   pro- 
phylaxis treatment  to,  416. 
Caries  of  bone,  see  osteitis,  chronic. 
Causes  of  various  diseases,  see  each  dis- 
ease. 
Cavities,   sharp  edges  of,   as  a   cause   of 

gingivitis,  134. 
Cementoblasts.  destruction  of,  in  cases  of 
chronic     suppurative     pericementitis, 
168. 
Cementoblasts    of    peridental    membrane, 

42. 
Cementum. 

absorption    by    denuded    cementum    of 
products  of  suppuration  and  putre- 
faction in  cases  of  chronic  suppu- 
rative pericementitis,  171. 
absorption  of  roots  of  permanent  teeth. 

33. 
a  specialized  tissiie,  31. 
attachment    of    planted    teeth    physio- 
logically unstable,  49. 
attachment  of  principal  fibers  of  peri- 
dental membrane,  34. 
chemotaxis,  48. 
continuous  growing,  34. 
ilifferenees  between  cementum  and  bone, 

32. 
diseases,  62. 

does  not  rei)air  injuries,  32,  42. 
extent  to  which  denuded  in  chronic  ab- 
scess, 371. 
functions  of,  7,  30,  31,  45. 

as  shown  by  planted  teeth,  45. 
histological  studies  of,  30. 
histology  of,  7,  30,  31. 
historical   review  of  knowledge  of  dis- 
eases, 64. 
hypercementosis,  35. 
in  animals,  35. 

maintains    chronicity    of    alveolar    ab- 
scess, if  denuded,  341.  363,  407. 
iiiaLnfains  chronicity  of  chronic  suppu- 
rative   pericementitis,   if   denuded, 
168,  171.  407. 


480 


SPECIAL    DENTAL    PATHOLOGY. 


Omentum  (continued). 

pathological    absorption    of    roots    of 

permanent  teeth,  33. 
physical  functions  of,  1,  30,  31,  45. 

as  shown  by  planted  teeth,  45. 
repairs    of    absorptions    of    cemeutura 

and  dentin,  33,  42. 
subject  to  absorption,  32. 
treatment,  62. 

Cervical  glands,  enlargement  of,  in  cases 
of   chronic   suppurative   pericementi- 
tis, 174. 
palpation  of,  174. 

Chemistry  of  deposits  of  calculus,  93. 

Chemotaxis,  48. 

Cheniotaxis  and  phagocytosis,  221. 

Chronic  alveolar  abscess,  see  abscess. 

Chronic  foci,  three  groups  of,  in  mouth, 
407. 

Chronic  infections  of  mouth,  systemic  ef- 
fects of,  398. 

Chronic  inflammation  of  the  pulp,  262. 

Chronic    suppurative    pericementitis,    see 
pericementitis. 

Classification  of  causes  of  injury  to  the 
gingivas,  129. 

Cleaning,  artificial,  lack  of,  as  a  cause  of 
gingivitis,  137. 

Cleaning,  natural,  lack  of,  as  a  cause  of 
gingivitis,  137. 

Cocain  for  pulp  anesthesia,  see  pulp. 

Composition  of  salivary  calculus,  73. 

Contacts,  weak,  as  a  cause  of  gingivitis, 
130. 

Crest  of  gingivae,  13. 

Criie's  theory  of  preventing  shock,  21. 

Crowns  as  a  cause  of  gingivitis,  131,  133, 
134. 

Cyst,  differential  diagnosis  from  alveolar 
abscess,  346. 

Cyst    formation,   epithelial  cells   of  peri- 
dental membrane  in  relation  to,  392. 

Decays  beginning  in  proximal  surfaces  as 

a  cause  of  gingivitis,  131. 
Deciduous  teeth,  treatment   of   pulps  of, 
320. 
better  care  desirable,  333. 
chronic  abscesses,  333. 
filling    of    deciduous    teeth    to    i)rotect 

pulps,  334. 
serious  results  of  exposures  of  pulps  of, 

331. 
technic   same  as  for   permanent   teeth, 

332. 
time  of  complete  calcification  and  be- 
ginning absorption  of  roots,  330. 
Defense  by  the  tissues,  408. 
Dentin,  effect  on,  of  calcifications  in  pulp 

chamber,  271. 
Dento-alveolar  pyorrhea,  66. 
Deposits,  form  of  gingivae  in  relation  to, 
27. 


Deposits  of  calculus,  see  gingivitis  caused 
by  deposits  of  salivary  calculus  and 
of  serimial  calculus. 

Deposits  of  serumal  calculus  on  enamel  as 
a  cause  of  chronic  suppurative  peri- 
cementitis, 161. 

Deposits,  removal  of,  106,  120,  191. 

Development  of  the  gingivae,  22. 

Deviations  from  normal  contour  of  teeth 
as  a  cause  of  gingivitis,  134. 

Diseases  of  investing  tissues  of  teeth,  62. 

Drainage,  351,  352,  357,  383. 

Embrasures,  definition,  18. 
Emetiu  hydrochlorate,  administration  of, 
in  cases  of  chronic  suppurative  peri- 
cementitis, 199. 
Enamel,    effect    on,    of    calcifications    in 

pulp  chamber,  271. 
Endameba  buccalis.  as  a  cause  of  chronic 

suppurative  pericementitis,  162. 
Epithelium  of  the  gingivae,  19. 
Epithelium  of  gums  and  gingivae,  9. 
Epithelium   of  the  peridental  membrane, 
43. 
in   relation   to   inflammations  and  cyst 

formation,  392. 
studies    by    German    histo-pathologists, 
44,  394. 
Epithelium  of  septal  gingivae,  20. 
Erosion,    calcification    of    pulp    resulting 
from,  see  calcification  of  pulp, 
treatment  of,  279. 
Errors  in  cleaning  operations  as  a  cause 

of  gingivitis,  138. 
Etiology  of  various  diseases,  see  each  dis- 
ease. 
Examinations  of  the  mouth,  447. 
card  for,  457. 

critical   examination   of   teeth   and   in- 
vesting tissues,  451. 
general  survey,  451. 
in  cases  of  chronic  suppurative  perice- 
mentitis, 206. 
instruments  for,  450. 
record  of,  456. 

routine  mouth  examination,  448. 
use  of  card,  457. 
Exploration  of  subgingival  spaces,  25. 
Exposure  of  the  dental  pulp,  see  pulp. 
Extracted    teeth    in    relation    to   alveolar 

process,  53. 
Extraction,  in   cases  of  chronic  suppura- 
tive   pericementitis,    when   indicated, 
202. 
Extractions,   separations   following,   as  a 
cause  of  gingivitis,  129. 

Fibers  of  the  gingiva?  and  peridental 
membrane,  14. 

Fibers  of  peridental  membrane,  destruc- 
tion of,  in  cases  of  chronic  suppura- 
•     tive  pericementitis,  168. 


INDEX. 


481 


Fibers  of  peridental  membrane,  strength 
of,  39. 

Fibrils  of  Tomes,  236. 

Fibrous  mat  of  gums  and  gingivae,  8. 

Filing    teeth,    and    resulting   injuries    to 
gingiva",  142. 

Filling  deciduous  teeth  to  protect  pulps, 
334. 

Filling  root  canals,  see  root  canals. 

Fillings  as  a  cause  of  gingivitis,  131.  133, 
134. 

Finishing   instruments,   injuries   with,   as 
a  cause  of  gingivitis,  136. 

Fixation  of  teeth  in  cases  of  chronic  sup- 
purative pericementitis,  201. 

Fixation  of  teeth  loosened  as  a  result  of 
deposits  of  salivary  calculus,  112. 

Forms  of  teeth,  physiological  importance 
of,  14.5. 

Free  gingiva?,  16. 

Free  gingivae  group  of  fibers  of  periden- 
tal membrane,  15. 

Frequency  of  different  fori^s  of  gingivi- 
tis, 139. 

Functions  of  dental  pulp,  235. 

Functions  of  the  gingivae,  26. 
a  protective  tissue,  26. 
maintenance  of  teeth  in  line  of  arch,  28. 

Functions  of  the  investing  tissues  of  the 
teeth,  7,  30,  31,  45. 
as  shown  by  planted  teeth,  45. 

Fused  teeth,  35. 

Gingiva,  gingivae,  7,  11. 

appearance   of,  in  chronic  suppurative 

pericementitis,  165. 
blood  supply,  9. 
body  of,  13. 
crest  of,  13. 

curvature  of  gingival  line,  25. 
development  of,  22. 
diseases,  see  gingivitis, 
epithelium  of,  9,  19. 

septal  gland,  20. 
fibers,  groups  of,  14. 
fibrous  mat  of,  8. 

form  of,  in  relation  to  deposits,  27. 
free  gingiva^,  16. 
functions  of  7,  26. 

a  protective  tissue,  26. 

maintenance  of  teeth  in  line  of  arch, 
28. 
healing  powers,  9. 
histology  of,  7. 

historical  review  of  knowledge  of  dis- 
eases, 64. 
hormone,  21. 
irregularities  of,  442. 
names  applied  to  diseases  of,  64. 
nomenclature  of,  13. 
parts  of,  13. 
phj^sical  functions  of,  7. 
primary  alveolar  ridge,  22. 
principal  fibers,  groups  of,  14. 


alveolar  ei-est  group,  16. 
free  gingiva  group,  15. 
trans-septal  group,  15. 
sensation,  9. 
septal  gingivcP,  17. 

epithelium  of,  20. 
subgingival  spaces,  24. 

exploration  of,  25. 
treatment,  see  gingivitis. 
Gingival  abscess,  179. 
Gingival  line,  curvature  of,  25. 
Gingivitis,  acute  ulcerous  230. 
Gingivitis  and   pericementitis  due  to  de- 
posits of  salivary  calculus,  99. 
admixtures  with  cases  of  chronic  sup- 
purative pericementitis,  182. 
attachment  of  peridental  membrane  to 
root   maintained    to   level   of   soft 
tissue  remaining,  100. 
beginnings  and  progress  of  deposit,  99. 
conditions    contributing    to    occurrence 

of  deposit,  102. 
deposit     usually     confined     to     certain 

teeth,  102. 
destruction  of  deeper  tissues,  100. 
form  which   gives  opportunity   for   de- 
posit, 103. 
forms    of   artificial    dentures    to   avoid 

deposits,  104. 
frequency  of  different  forms  of  gingi- 
vitis, 139. 
influence  of  mastication  in  preventing 

deposits,  104. 
menace  to  general  health,  102. 
pain  and  soreness,  101. 
positions  of  deposits,  variations  in,  102. 
suppuration,  100. 
teeth  become  loose  and  are  finally  lost, 

101.  ^ 

treatment,  105. 

care  of  tissues  by  dentist,  109. 
care  of  tissues  by  the  patient,  110. 
fixation  of  loose  teeth,  112. 
instruments      and       instrumentation, 

106. 
prophylaxis,  application  to,  420. 
removal  of  deposits,  106. 
rubber     bulb     syringe     for     rinsing 

mouth,  108. 
subsequent  examinations.  111. 
use  of  syringe  and  brush,  111. 
variations  in  position  and  progress  of 
deposit,  102. 
Gingivitis  due  to  deposits  of  serumal  cal- 
culus, 115. 
comparison    with    deposits    of    salivary 

calculus,  117. 
compression  of  deposits  by  the  gingi- 
va", 118. 
conditions  of  occurrence,  115. 
deposits,  causes  of,  115. 

comparison  witli  deposits  of  salivary 

calculus,   117. 
compressed  by  the  gingivse,  118. 


482 


SPECIAL   DENTAL    PATHOLOGY, 


Gi-ngivitis;  fine  to  deposits  of  serunial  cal- 
culus (coiiti  lined), 
removal  of,  120. 
variations  in  location,  IIS. 
frequency  of  different  forms  of  gingi- 
vitis, 139. 
gingivitis  due  to  the  deposit,  117. 
treatment  of,  120. 
care  by  patient,  124. 
care  of  tissues  by  dentist,  123. 
instruments,  instrumentation,  121. 
prophylaxis,  application  to,  421. 
removal  of  de{)()sits,  120. 
subsequent  examinations,  124. 
use  of  syringe,  123. 
suppuration   involving  peridental  mem- 
brane, 118. 
variations  in   location   of   the   deposits, 
118. 
(iingivitis  caused  by  injuries,  125. 
absorption  of  septal  tissues,  128. 
causes,  classification,  129. 

abnormalities  of  occlusion,  130. 
abnormal  forms  of  teeth,  131. 
abuse  of  tissues  in  dental  operations, 

13.5. 
accidental  injuries,  139. 
bridges,  134. 

cavities,  sharp  edges  of,  134. 
cleanliness,  lack  of  artificial,  137. 
cleanliness,  lack  of  natural,  137. 
crowns,  improperly  finished,  133. 
of  improper  form,  134. 
which  fail  to  make  contact,  131. 
decays  in  proximal  surfaces,  131. 
dentures,  partial,  134. 
deviations   from   normal   smooth  con- 
tour of  teeth,  134. 
^         en-ors  in  cleaning,  138. 

fillings,  improperly  finished,  133. 

which  fail  to  make  contact,  131. 
finishing    instnimeuts  and   tapes,   in- 
juries with,  13.5. 
general  statement,  126. 
improper  contact  of  teeth,  131. 
interproximal  wear,  132. 
lack  of  contiict  of  teeth,  129. 
ligatures,  injuries  with,  135. 

not  removed,  136. 
malj)03itions  of  teeth,  132. 
rubber  bands,  misuse  of,  139. 
rubber  dam,  pieces  of,  not  removed, 

136. 
separations      following      I'xtractions, 

129. 
silk  floss,  misuse  of,  139. 
tooth-brush,  injuries  with,  139. 
toothpicks,  misuse  of,  138. 
uneven  occlusal  wear,  130. 
weak  contact,  130. 
deposits  of  serumal  calculus,  128. 
filing    teeth    and    resulting    injuries    to 
gingivae,  142. 


frequ(!ncy  of  different  forms  of  gingi- 
vitis, 139. 
general  statement  of  causes  and  symp- 
toms, 126. 
history    of    attitude    of    profession    to- 
ward, 141. 
inflammation,  126. 

noncohesive   gold,  use   of,  and   injuries 
to  gingiva'  in  connection  with,  142. 
pain,  complaint  of.  variable,  127. 
Perry  separator,  153. 
pro{)hylaxis,  application  to,  421. 
septal  tissue,  absorption  of,  128. 
suppuration,  127. 
symptoms,  general  statement,  126. 
tooth    forms,   physiological    importance 

of,  145. 
treatment  of,  147. 

improper  contact  of  teeth,  treatment 

in  cases  of,  150. 
lack  of  contact  of  teeth,  treatment  in 

cases  of,  148. 
more   careful    study   of   cases   neces- 
sary, 151. 
occlusion,    danger    of    disturbing,    in 

restoring  contact,  149. 
separation,    exact    method    necessary 

in  building  contacts.  152. 
wedge,  wooden,  and  injuries  to  gingi- 
va resulting  from  use  of,  144. 
Glands,  differential  diagnosis  from  alveo- 
lar abscess,  347. 
Globulin,  88. 
Gnathodynamometer,  tests  of  strength  of 

fibers  of  jieridental  membrane,  40. 
Gold  foil,  discovery  of  cohesive  property 

of.  142. 
(Sold,  noncohesive,  use  of,  and  injuries  to 

gingiva'  in  connection  with,  142. 
Gouty  diathesis  in  relation  to  disease  of 

peridental  memljrane,  67. 
Gumma,    differential    diagnosis    from    al- 
veolar abscess,  346. 
Gums,  7. 

an  immobile  tissue,  8. 
blood  supply,  9. 
epithelium,  9. 
fibrous  mat  of,  8. 
functions  of,  7. 
healing  )iowers,  9. 
histology  of,  7. 
]ihysical  functions  of,  7. 
sensation,  9. 
Guttapercha  for  sealing  treatments,  292. 

Healing  ))owers  of  dental  pulp,  243. 

Healing  ))owers  of  gums  and  gingivae,  9. 

Health    menaced   by   deposits  of   salivary 
calculus,  102. 

Histological    studies    of    peridental    mem- 
brane, 30. 

Histological    structure,    of    investing    tis- 
sues of  the  teeth,  7,  30,  31. 
of  dental  pulp,  235. 


INDEX. 


483 


Historical     review     of     development     of 
knowledge    of   diseases   of   investing 
tissues,  64. 
Historical  statement  re  diseases  of  dental 

pulp,  248. 
History  of  attitude  of  profession  toward 

injuries  to  the  gingivae,  141. 
Horizontal  group  of  fibers  of  peridental 

membrane,  37. 
Hormone.  21. 

Hunter,  John,  teeth  planted  by,  4.5,  48. 
Hunter's  pajjer  on  oral  sepsis,  398. 
H3'gieno  of  mouth,  see  mouth  hygiene. 
Hypereementosis,  35. 
Hyperemia  of  dental  pulp,  254. 
author's  studies  of,  251. 
etiology,  254. 
historical  statement,  248. 
pathological  changes,  255. 
preventive  treatment,  298. 
avoid  near  approach,  299. 
thorough  and  frequent  examinations, 

299. 
use  of  nonconductors,  300. 
sequela?,  256. 
symptoms,  256. 

technie  of  preparing  specimens,  251. 
treatment  of,  300. 
Hypertrophy  of  the  dental  pulp,  262. 
diagnosis,  263. 

differential    diagnosis    from    hypertro- 
phy of  septal  gingiva,  263. 
treatment  of,  264. 

Immobility  of  gum  tissue,  8. 

Implantation,  47. 

Improper  contact  of  teeth  as  a  cause  of 

gingivitis,  131. 
Incisors,   upper,   labial   movement   of,   in 
cases  of  chronic  suppurative  perice- 
mentitis, 176. 
Indefinite  connective  tissue  of  peridental 

membrane,  40. 
Infection,  special,  as  a  cause  of  disease 

of  peridental  membrane,  68. 
Infection,  specific,  as  a  cause  of  chronic 

suppurative  pericementitis,  162. 
infianiniation  of  the  dental  pulp,  258. 
author's  studies,  251. 
chronic  inflammation,  262. 
diagnosis,  261. 

exposed  to  carious  dentin,  261. 
pain.  261. 
etiology,  258. 
historical  statement,  248. 
pathological  changes,  259. 
preventive  treatment,  298. 
avoid  near  approach,  299. 
thorough  and  frequent  examinations, 

299. 
use  of  nonconductors,  300. 
technie  of  preparing  specimens,  251. 
technie  of  treatment,  see  pulp, 
treatment  of  hyperemia,  300. 


Injuries  to  gingivae  as  a  cause  of  chronic 
suppurative  pericementitis,  161. 

Injuries  to  the  gingiva?,  see  gingivitis 
caused  by. 

Instruments  for  mouth  examination,  450. 
for  removing  deposits,  106,  121,  192. 

Interproximal  wear  as  a  cause  of  gingi- 
vitis, 132. 

Interstitial  gingivitis,  66. 

Introduction,  1. 

Investing  tissues,  see  gingiva;,  peridental 
membrane,  cementum,  alveolar  pro- 
cess. 

Irrigation  in  cases  of  acute  alveolar  ab- 
scess, 354. 

Lack  of  cleanliness  as  a  cause  of  gingi- 
vitis, 137. 

Lack  of  contact  of  teeth  as  a  cause  of 
gingivitis,  129. 

Lateral  alveolar  abscess,  179. 

Ligatures,  injuries  with,  as  a  cause  of 
gingivitis,  135,  136,  139. 

Loosening  of  teeth  in  chronic  alveolar 
abscess,  369. 

Machine   for   grinding   microscopic  speci- 
mens, 460. 
Malposed  teeth  in  relation  to  development 

of  alveolar  process,  53. 
Malposition  of  teeth  as  a  cause  of  gingi- 
vitis, 132. 
Management  of  cases  of  chronic  suppura- 
tive pericementitis,  206. 
Mastication,    intluence   of,   in   preventing 

deposits  of  salivary  calculus,  104. 
Medication  in  pulp  treatment,  see  pulp. 
Microsco])ic      sj)ecimens,      machine      for 

grinding,  460. 
Mouth  hygiene,  423. 

artificial  cleaning  unnecessary  for  some 

persons,  441. 
artificial  dentures,  442. 
bridges,  442. 
care  of  brush,  431. 
care  of  the  mouth,  425. 
dentist  sliould   put  mouth   in  condition, 

437. 
irreguhirities  of  gingivue,  442. 
?nouth  washes,  436. 
movements  of  tooth-brush,  429. 
popular  education,  423. 
rubber  bands,  432. 
silk  floss,  432. 
syringe,  433. 

syringe  wlien  gingivie  arc  inflamed,  436. 
technie  of  cleaning  the  mouth,  427. 
temporary  teeth,  care  of,  425. 
tooth-brushes,  427. 
tooth-pastes,  436. 
toothpicks,  431. 
tooth-powders,  436. 
training  in  cleaning,  439. 
when  cleaning  should  be  done,  438. 


484 


SPECIAL   DENTAL   PATHOLOGY, 


Mouth  washes,  436. 

Movements  of  teeth  in   chronic  suppura- 
tive pericementitis,  175. 
labial  movement  of  upper  incisors,  176. 
multiple  pocket  formation,  178. 
Movements  of  teeth  subsequent  to  extrac- 
tions, 54. 
Mucus,  in  saliva,  58. 

function  of,  59. 
Multiple    pocket    formation    in    cases    of 
chronic     suppurative     pericementitis, 
178. 

Xeerosis  of  the  maxilliB,  380. 
etiology,  381. 
symptoms,  381. 
treatment,  382. 

anodynes,  384. 

cathartics,  384. 

cleanliness,  383. 

extract  loose  teeth,  383. 

prophylaxis,  386. 

removal  of  sequestra,  384. 

secure  good  drainage,  383. 
Nerves  and  nerve  functions  of  pulp,  238. 
Nerves  of  peridental  membrane,  40. 
Nomenclature  of  the  gingiva^,  13. 
Noncohesive  gold,  use  of,  and  injuries  to 

gingiva?  in  connection  with,  142. 
Nonconductors,  in  pulp  treatment,  300. 

Oblique  group  of  fibers  of  peridental  mem- 
brane, 37. 
Occlusal  wear,  uneven,  as  a  cause  of  gin- 
givitis, 130. 
Occlusion,  abnormalities  of,  as  a  cause  of 
gingivitis,  130. 
danger  of  disturbing  in  restoring  con- 
tacts, 149. 
Odontoblasts,  236. 
Oral  prophylaxis,  411,  413. 
Oral  prophylaxis  treatment,  415. 
application  to  dental  caries,  416. 
application    to    diseases    of    peridental 

membrane,  420. 
application    to    gingival    third    decays, 

419. 
application  to  gingivitis  caused  by  de- 
posits of  salivary  calculus,  420. 
aj)plication  to  gingivitis  caused  by  de- 
posits of  serumal  calculus,  421. 
application  to  gingivitis  caused  by  in- 
juries, 421. 
application    to    pit   and   fissure   decays, 

417. 
application  to  proximal  decays,  418. 
summaiy,  421. 
Oral  sepsis.  Dr.  Hunter's  paper,  398. 
Osteitis,  chronic,  of  maxilla?,  388. 
etiology,  388. 
symptoms,  389. 
treatment,  390. 
Osteoblasts  of  peridental  membrane,  41. 


Pain  and  touch,  senses  of  tooth,  240. 
Pain,  caused  bv  deposits  of  salivary  calcu- 
lus, 101. 
complaint  of  variable,  in  injuries  to  gin- 
giva', 127. 
disappears  with  discharge  of  pus,  345. 
in  acute  alveolar  al^scess.  344. 
in  clironic  alveolar  abscess,  368. 
in    chronic    suppurative    pericementitis, 

172. 
in  connection  with  deposits  of  salivary 

calculus,  101. 
in  inflammation  of  the  pulp,  261. 
in  scaling  operations,  in  cases  of  chronic 

suppurative  pericementitis,  196. 
in  severe  cases  of  alveolar  abscess,  356. 
location  of,  uncertain  when  pulp  is  in- 
volved, 241. 
of   other  diseases  simulates  pulp  pain, 
242. 
Palliative  treatment  of  chronic  suppura- 
tive pericementitis,  190. 
Pare,  Ambroise.  t^eth  planted  by,  45. 
Paroxysmal  characters  of  deposits  of  cal- 
culus, 84. 
Partial  dentures  as  a  cause  of  inflamma- 
tion of  the  gingivae,  134. 
Pathological  changes  in  various  diseases, 

see  each  disease. 
Pericementitis,  chronic  suppurative,  159. 
abscess  in  cases  of,  1 79. 

differential  diagnosis  from  true  alve- 
olar abscess,  181. 
absorption     of    alveolar    process    best 

shown  by  radiographs,  169. 
admixtures,  with   inflammations  caused 
by    deposits    of    salivars'    calculus, 
182. 
amputation  of  roots  in,  205. 
antiseptics,   abandonment   of,    in   treat- 
ment, 210. 
appearance  of  tlie  gingiva-,  165. 
cases  tend  to  progress,  168. 
causes,  161. 
cervical  glands,  enlargement  of,  174. 

palpation  of,  174. 
chronicity   maintained  by   denuded   ce- 

mentum,  168,  171,  407. 
cleanliness,  treatment  by,  213. 
defense  by  the  tissues,  213. 
deposits  of  serumal  calculus,  172. 
contribute  to  progress,  173. 
occurrence  of,  173. 
often  nodular,  172. 
destruction  of  cementoblasts,  fibers  of 
peridental  membrane  and  the  alve- 
olar process,  168. 
emetin  hvdrochlorate,  administration  of, 

199.' 
endameba  buccalis  as  a  cause,  162. 
extraction,  when  indicated,  202. 
failures  of  reattachment,  167. 
first  description  of  j)us  pocket,  159. 
gingival  abscess.  179. 


INDEX. 


485 


Pericementitis,  chronic  suppurative   (con- 
tinued ) . 
gingivitis  always  precedes,  161. 
granular  condition  of  soft  tissue  cover- 
ing root,  171. 
incisors,  upper,  labial  movement  of,  176. 

may  move  forward  of  normal  position 
of  labial  process,  177. 
infection  and  detachment,  166. 
infection,  specific,  as  a  cause,  161. 
injuries  to  gingivae  as  a  cause,  161. 
key  to  treatment,  185. 
labial  movement  of  upper  incisors,  176. 
lateral  alveolar  abscess,  179. 
locations  of  pus  pockets,  164. 
management  of  cases,  206. 

examination,  206. 

plan  of  treatment  for  each  case,  208. 

radiographs,  207. 
movements  of  teeth  in,  175. 
multiple  pocket  formation,  178. 
palliative  treatment  of,  190. 

care  by  patient,  197. 

care  of  tissues  by  dentist.  197. 

emetin  hj^droehlorate,  administration 
of,  199. 

finger  skill  very  essential,  194. 

instruments,  192. 

instrumentation,  193. 

leave  roots  smooth,  195. 

pain  in  scaling  operations,  196. 

plan  for,  191. 

removal  of  deposits,  191. 

scalers  must  be  sharp,  194. 

subsequent  examinations,  198. 

surgical  treatment  of  pockets,  199. 

use  of  splints,  201. 
preventive  treatment  of,  186. 

by  general  practitioners,  187. 

care   to   avoid   injuries  to  tissues  in 
operating,  188. 

lingual  gingiva",  upper  Incisors,  inju- 
ries to,  189. 

plan  for,  186. 

septal  tissues,  injuries  to,  188. 

systematic  observation,  187. 

training  of  patients,  189. 

treatment  should  l)e  instituted  early, 
187. 
progress  most  toward  apex  of  root,  167. 
pus  pockets,  locations  of,  164. 
radical  treatment,  202. 

amputation  of  roots,  205. 

when  indicated,  202. 
reattaclunent,  failures  of,  167. 
salivary  glands,  excitement  of,  175. 
septal  abscess,  1 79. 
serumal  calculus,  deposits  of,  172. 

contribute  to  progress,  173, 

occurrence  of,  173. 

often  nodular,  172. 

on  enamel,  as  cause  of,  161. 


sentiment  in  relation  to  treatment  of, 

209. 
splints,  use  of,  201. 
surgical  treatment  of  pockets,  199. 
symptoms,  164,  165. 
systemic  conditions  as  a  cause,  161. 
tissue  changes,  164,  165. 
training  of  patients  to  prevent,  189. 
treatment  by  cleanliness,  213. 
treatment  of,  185. 
palliative,  190. 
preventive,  186. 
radical,  202. 
Pericementitis  due  to  deposits  of  salivary 

calculus,  see  gingivitis. 
Pericementitis,  in  alveolar  abscess,  337. 
Peridental  membrane. 

ability  to  repair  injuries,  36. 
attachment  of  planted  teeth  physiolog- 
ically unstable,  49. 
attaclmient   of   principal   fibers   to   ««•- 

mentum,  34. 
blood  vessels  of,  40. 
cementoblasts  of,  42. 
changes  in   tissues  in  cases  of  chronic 

suppurative  pericementitis,  165. 
chemotaxis,  48. 
curvature  of  gingival  line,  25, 
destruction  of  cementoblasts  and  fibers 
in    cases    of    chronic    suppurative 
pericementitis,  168. 
destruction  by  deposits  of  salivary  cal- 
culus, 100. 
diseases,  62. 
Dr.   Eehwinkel's  paper  on   diseases  of, 

67. 
Dr.  Eiggs'  treatment,  67. 
epithelial  cells  of,  in  relation  to  inflam- 
mations and  cyst  formation,  392. 
epithelium  of,  43. 

recent  studies  of,  44. 
failures  of  reattachment  when  detached 

by  suppuration,  167. 
fibers,' 14,  36. 

groups  of,  14,  36. 
alveolar  crest  group,  16. 
apical  group,  39. 
free  gingiva*  group,  15. 
horizontal  group,  37. 
oblique  group,  37. 
trans-septal  group.  15. 
functions  of,  7,  30,  36,  45. 

as  sliown  by  planted  teeth,  45. 
goutv  diathesis  in  relation  to  diseases 

of,  67. 
histology  of,  7,  30,  36, 
liistorical  review  of  knowledge  of  dis- 
eases, 64. 
indefinite  connective  tissue  of,  40. 
movements  of  teeth  subsequent  to   ex- 
tractions, 54. 
names  ai)plied  to  diseases  of,  64. 
nerves  of,  40. 


486 


SPECIAL    DENTAL   PATHOLOGY. 


Peridental  membrane  (continued), 
osteoblasts  of,  4L 
physical  functions  of,  7,  30,  36,  45. 

as  shown  by  planted  teeth,  45. 
principal  fibers,  groups  of,  see  fibers, 
results  to  alveolar  process  from  break  in 

peridental  membrane,  53. 
serum  treatment,  70. 
special   infection  as  a  cause  of  disease 

of.  as. 

strength  of  fibers  of,  39. 
supjiurations  involving,  in  cases  of  gin- 
givitis  caused   by   deposits   of   se- 
rumal  calculus,  118. 
touch  sense  for  tooth  in  peridental  mem- 
brane, 41,  243. 
treatment,    see    gingivitis    and    perice- 
mentitis, 
treatment  in  vogue,  71. 
Perry  separator,  153. 
Phagedenic  pericementitis.  65,  159. 
Phagocytosis  and  ehemotaxis,  221. 
Phenol   to  make  opening  in  alveolar  ab- 
scess. 353. 
Physical  functions  of  dental  pulp,  235. 
Physical  functions  of  the  investing  tissues 

of  the  teeth.  7,  30.  31.  45. 
Physiological  salt  solution,  109,  123,  197, 

232,  354,  436. 
Planted  teeth  as  showing  physical  powers 
of  investing  tissues,  45. 
attachment  physiologically  unstable,  49. 
by  Ambroise  Pare,  45. 
by  John  Hunter,  45,  48. 
no  histo-]iatIiologicaI  studies,  47. 
Popular  education  re  mouth  hygiene,  423. 
Preventive  treatment  of  various  diseases, 

see  each  disease. 
Primary  alveolar  ridge,  22. 
Principal  fibers,  groups  of,  in  the  gingivae 

and  peridental  membrane,  14. 
Principal  filM>rs  of  peridental  membrane, 

attachment  to  cementum,  34. 
Probe,  sharp,  steel,  for  examination,  371. 
Prophylactic  teaching  relative  to  deposits 
of  salivary  calculus  on  basis  of  knowl- 
edge of  hardening,  95. 
Projjhvlaxis.  against  necrosis,  386. 
ajiplicd  to  alveolar  abscess,  360. 
general,  411. 
oral,  411,  413. 
Protective  function  of  gii3giva>,  26. 
Ptyalin,  in  saliva,  56. 
Pulp,  dental. 

anesthetizing  with  eocain,  308. 

requires  pressure  to  secure  anesthesia, 

309. 
when  pulp  is  not  exposed,  309. 
an  internal  organ,  241. 
arsenic,  destroying  with,  307. 
application  of,  307. 
danger  of  poisoning,  308. 
prevention  of  i)ressure,  307. 


sealing  with  gutta-percha,  292. 
subsequent  treatment   if  only   partly 
devitalized,  308. 
asepsis,  see  treatment,  technic. 
blood  vessels,  236. 

walls  of.  237. 
calcifications  in  )iulp  chamber,  see  calci- 
fications, 
calcifications  of,  effect   on    pulji   tissue, 

calcification  of  roots,  time  of,  303. 
calcific     deposits,     treatment     of     pulp 
cliambers    and     root    canals     nar- 
rowed by,  324. 
removal    of    calcifications    from    root 
canals,  325. 
capping     exjiosed     pulps,     history     of 

efforts,  244. 
capping  exposures  of,  301. 
indications  for  capping,  303. 
teehnic  of  capping,  30.3. 
time  of  complete  calcification  of  roots, 
303. 
cellular  elements  of,  235. 
chamber,  opening  of,  preparatory  to  re- 
moval, 310. 
in  bicuspids  and  molars,  320. 
in  incisors  and  cuspids,  312,  318. 
in  occlusal  cavities  in  molars,  310. 
in  proximal  cavities  in  molars,  312. 
in  sound  teeth,  318. 
chronic   alveolar   abscess,    condition   of 

pulp,  363,  369. 
completion  of  roots,  time  of,  303. 
dead  pulps,  treatment  of  teeth  having, 
321. 
asepsis,  322. 

conditions  presenting,  321. 
danger  of  periapical  infection,  323. 
instrumentation,  322. 
seal  treatments,  323. 
technic,  322. 
deciduous  teeth,  treatment  of  pulps  of, 

see  deciduous  teeth, 
diseases  of,   248.     See  also  hyjjeremia, 

inflammation,  calcifications, 
exposed  pulj)s.  history  of  efforts  to  save 

by  capping,  244. 
exposure  of,  304. 

by  abrasion  and  erosion,  272. 

conditions  presenting,  304. 

exjtosure  with  broad  instrument,  305. 

in  bicusjiids  and  molars,  305. 

in  ])roximal  cavities  in  incisors,  306. 

medication    to    reduce    inflammation, 

306. 
0|>ening  the  cavity,  304. 
rublicr  dam  on,  305. 
when  jiain  in  uncontrollable,  307. 
healing  powers,  243. 
histology  and  physical  functions,  235. 
historical  statement  re  diseases  of,  248. 
hyperemia  of,  see  hyperemia. 


INDEX. 


487 


Pulp,  dental  (continued). 

hypertrophy  of,  see  hypertrophy, 
infection  from,  in  alveolar  abscess,  341. 
inflammation  of,  see  inflammation, 
medicaments    used    in    pulp    treatment, 

experiments  with,  296. 
nerves  and  nerve  functions,  238. 
nodules,  see  calcifications, 
odontoblasts,  236. 

open  pulp   chamber  after  acute  symp- 
toms have  subsided  in  alveolar  ab- 
scess. 35.3. 
pain  and  touch,  240. 
pain,  location  of,  uncertain,  241. 
pain   of   other   diseases  simulates   pulp 

pain,  242. 
removal  of,  313. 
broaches,  313. 
technic  of  removal,  314. 
root  canals,  location  of,  in  lower  molars, 
316. 
in  upper  molars,  314. 
variations   in    forms    of   pulp    cham- 
bers, 318. 
root  fillings,  removal  of,  325. 
roots,  time  of  complete  calcification  of, 

303. 
sensoiy  function,  239. 
sui)puration  of,  see  inflammation, 
technic  of  prejiaring  si>ecimens  of,  251. 
technic  of  capping  exposures,  303. 
touch  sense  is  in  peridental  membrane, 

243. 
treatment  of  hyperemia  of,  see  hyper- 
emia, 
treatment   of  inflammation   of,  see  in- 
flammation, 
treatment,  technic  of,  286. 
asepsis,  287. 
asepsis,  plan  for,  288. 
general  considerations,  286. 
medication  of  pulp  and  root  canals, 

rationale,  295. 
rubl>er  dam,  application  of,  288. 
sealing  treatments,  292. 

with  base-jtlate  gutta-percha,  292. 
sterilization     of     broaches     wrapped 

with  cotton,  289. 
sterilization  of  field,  289. 
sterilization    of     instruments,    dress- 
ings, etc.,  289. 
surgically  clean  hands,  292. 
technic    of    wrapping    cotton    on 
broaches,  290. 
variations  in   forms  of   pulp  chamljers, 

318. 
vital  })uii)S,  treatment  of,  304. 
Pus,  discharge  of,  in  chronic  alveolar  ab- 
scess, 369. 
Pus  formatinii  in  itivcolar  abscess,  337. 
Pus    pockets,    see    i)eri('enientitis,    chronic 

suppurative. 
Pyorrhea  alvcolaris,  61. 


Eadiograpiis,  in  chronic  alveolar  abscess, 
371. 
of   cases   of   chronic   suppurative   peri- 
cementitis, 207. 
to  show  absorptions  of  alveolar  process, 
168. 
Eehwinkel's  paper  on  pyorrhea  alveolaris, 

67. 
Eepairs  of  absorptions  of  cementum  and 

dentin,  33,  42. 
Eepair  of  cementum,  32,  33,  42. 
Beplautation,  46. 

Resection  of  roots  in  chronic  alveolar  ab- 
scess, 378. 
Eesidual  alveolar  ridge,  209. 
Eiggs'  disease,  64. 
Eiggs"  treatment,  67. 

Eoot  amputation   in  clironie  alveolar  ab- 
scess, 379. 
Eoot  canal,  treatment  of,  in  chronic  alve- 
olar abscess.  375. 
Eoot  canals,  filling  of,  326. 

apical    foramen,    determining    size    of, 

327. 
canals  grouped  into  two  classes,  329. 
chloro-percha,  for,  328. 

to  prevent  evaporation  of  chloroform 
from,  329. 
gutta-percha  for,  327. 
horns  of  pulp  chambers,  329. 
large  canals,  technic  for,  327. 
length  of  root,  determining,  326. 
location  of  canals  in  molar  teeth,  314, 

316. 
rationale  of  procedure,  328. 
small  canals,  technic  for,  328. 
Root  resection  in  chronic  alveolar  abscess, 

378. 
Roots,  time  of  complete  calcification  of, 

303. 
Eosenow's  studies  of  systemic  effects  of 

chronic  foci  of  mouth,  403. 
Eubber  liands,  misuse   of,   as  a   cause   of 

gingivitis,  139. 
Eubber  bands,  see  mouth  hygiene. 
Eubber  bulb  svringe.   108,  109,  111,  123, 
197,  232,  354,  43.3,  438. 
use  by  patients.  111,  123,  197.  433,  436. 
Eubber  dam,  application  of,  in  pulp  treat- 
n)ent,  288,  305. 
discovery  of,  145. 
pieces  of,  as  a  cause  of  gingivitis,  136. 

Saliva,  5o. 

studies  of,  in  relation  to  deposits  of  sali- 
vary calculus,  see  salivary  calculus, 
albumin,  60. 
carbon  dioxid,  56,  76. 
constituents,  55. 
nuu'us.  58. 

function  of,  59. 
ptyalin,  56. 
saliva r}'  corpuscles,  so  called,  61. 


488 


SPECIAL    DENTAL.    PATHOLOGY. 


Salivary  calt'uhis. 
agglutinin,  73,  89, 
analysis  of,  74. 
author's  investigations,  79. 
caleo-globulin  in  other  secretions,  96. 
calculi  from  salivary  glands,  SS. 
calculus  from  kidney,  88. 
carbon  dioxid  in  relation  to,  77. 
chemistry  of  deposits,  93. 
classification  of  deposits,  80,  84. 
collection  of  deposits  on  cover-glass,  81. 
comparison   of   serumal   calculus   with, 

117. 
composition  of,  73. 
conclusion  of  author,  97. 
deposits  during  illness,  91. 
Dr.  Burchard's  studies,  76. 
eosin  stain,  82. 
explanatoi-y  supposition,  95. 
gathering  calculus  direct  from  parotid 

gland,  86. 
gentian  violet  stain,  82. 
gingivitis  and  pericementitis  due  to,  see 

gingivitis, 
globulin,  88. 

globulin  and  salts  inseparable,  91. 
hardening  of  deposits,  73,  94. 
knowledge  of  hardening  basis  for  pro- 

]ihvlaetic  teaching,  95. 
method  of  preparing  specimens,  90. 
mucus  in  relation  to.  78. 
nigrosin  stain,  83. 

]iaroxysmal  characters  of  deposits,  84. 
prophylactic  teaching  on  basis  of  knowl- 
edge of  hardening,  95. 
spherules,  consistency  of,  89,  90. 
staining  deposits,  81. 
studies  of,  73. 
test  of  saliva  for  precipitate  of  calcium 

salts,  79. 
trap  for  collecting  deposits,  81,  103. 
Salivary  corpuscles,  so  called,  61. 
Salivary  glands,  excitation  of,  in  cases  of 
chronic     suppurative     pericementitis, 
175. 
Salt  solution,  see  physiological  salt  solu- 
tion. 
Sarcoma,  differential  diagnosis  from  alve- 
olar abscess,  346. 
Scalers,  set  of,  for  removing  deposits  in 
cases  of  chronic  suppurative  perice- 
mentitis, 192. 
Scalers,  set  of,  for  removing  deposits  of 
salivary  calculus,  106. 
for  removing  deposits  of  serumal  calcu- 
lus, 121,  192. 
Secondary'    dentin,    see    calcifications    in 

pulp  cliamber. 
Sensation  of  gums  and  gingiva^,  9. 
Sense   of   touch    for   tooth    in    peridental 

membrane,  41. 
Sensory  function  of  pulp,  239. 


Sentiment  in  relation  to  treatment  of  cases 
of  chronic  suppurative  pericementitis, 
209. 
Separation  of  teeth,  exact  method  neces- 
sary in  restoring  contacts,  152. 
Separation,    slow,    with    the    Perry    sepa- 
rator, 155. 
Separations    following    extractions    as    a 

cause  of  gingivitis,  129. 
Separator,  Perry,  153. 
Septal  abscess,  179. 
Septal  gingiva*,  17. 
epithelium  of,  20. 
Septal  gland,  20. 
Septal  space,  definition,  18. 
Septal  tissue,  absorption  of,  in  cases  of 

injury,  128. 
Sequestra,  removal  of,  384. 
Serum  treatment  for  disease  of  peridental 

membrane,  70. 
Serumal  calculus,  gingivitis  caused  by,  see 

gingivitis. 
Sermnal  calculus. 

as  cause  of  gingivitis,  see  gingivitis, 
deposits  of,  in  cases  of  chronic  suppura- 
tive pericementitis,  172. 
deposits  of,   on  enamel,  as  a  cause  of 
chronic  suppurative  i>ericementitis, 
161. 
Silk  floss,  injuries  with,  as  a  cause  of  gin- 
givitis, 136,  139. 
Silk  floss,  see  mouth  hygiene. 
Sinus,  see  abscess,  chronic  alveolar. 
Soreness  of  teeth  resulting  from  deposits 

of  salivary  calculus,  101. 
Sterilization,   of   broaches   in   pulp   treat- 
ment, 289. 
of  broaches  wrapped  with  cotton,  289. 
of  field  in  pulp  treatment,  289. 
Studies  of  salivary  calculus,  73. 
Subgingival  spaces,  24. 

exploration  of,  25. 
Submaxillary  glands,  palpation  of,  174. 
Suppuration  as  a  result  of  deposits  of  sali- 
vary calculus,  100. 
Suppuration  in  injuries  to  gingiva,  127. 
Su])puration  of  the  pulp,  259. 
Suppurative  pericementitis,  see  pericemen- 
titis. 
Siu'gically  clean  hands  for  pulp  treatment, 

292. 
Symptoms   of   various   diseases,   see   each 

disease. 
Syringe,  see  mouth  hygiene,  433. 
Svringe,  rubber  bulb,  "use  of,  108,  109,  111, 

123,  197,  232,  354,  433,  436. 
Systemic  conditions  as  a  cause  of  chronic 

suppurative   pericementitis,   161. 
Svstemic  effects  of  chronic  infections  of 
mouth,  398. 
Billings"  investigations,  401. 
defense  by  the  tissues,  408. 
dentist's  opportunity,  409. 
Hunter's  paper  on  Oral  Sepsis,  398. 


INDEX. 


489 


Systemic,  effects  of  cliroiiic  infections  of 
the  mouth  (continued), 
organisms  in  primary  focus,  405. 
Rosenow's  studies,  403. 
summary,  409. 

three  groups  of  chronic  foci  in  mouth, 
407. 

Tapes,  injuries  with,  as  a  cause  of  gingi- 
vitis, 136. 

Technic  of  preparing  specimens  of  pulp 
tissue,  251. 

Teeth  maintained  in  line  of  arch  by  gingi- 
vae, 28. 

Tenderness  of  tooth  in  chronic  alveolar 
abscess,  368. 

Third  molars,  eruption  of,  differential 
diagnosis  from  alveolar  abscess,  347. 

Tie  douloureux,  242. 

Tooth-brush,  injuries  with,  as  a  cause  of 
gingivitis,  139. 

Tooth-brushes,  see  mouth  hygiene. 

Tooth  pastes  arid  powders,  436. 

Toothpicks,  misuse  of,  as  a  cause  of  gingi- 
vitis, 138. 


Toolhpicks,  see  mouth  hygiene. 

Tomes,  fibrils  of,  236. 

Touch  and  pain  senses  of  tooth,  240. 

Touch  sense  for  tooth  in  peridental  mem- 
brane, 41,  243. 

Training  of  patients  to  prevent  chronic 
suppurative  pericementitis,  189. 

Transplantation,  46. 

Trans-septal  group  of  fibers  of  periden- 
tal membrane,  15. 

Traps  for  collecting  deposits  of  salivary 
calculus,  81,  103. 

Treatment  of  various  diseases,  see  each 
disease. 

Weak  contacts  as  a  cause  of  gingivitis, 
130. 

Wear,  interproximal,  as  a  cause  of  gingi- 
vitis, 132. 

Wear,  uneven,  of  occlusal  surfaces,  as  a 
cause  of  gingivitis,  130. 

Wedge,  wooden,  and  injuries  to  gingivae 
resulting  from  use  of,  in  separating 
teeth,  144. 


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